Andover Manor Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Andover, Massachusetts.
- Location
- 89 Morton Street, Andover, Massachusetts 01810
- CMS Provider Number
- 225294
- Inspections on file
- 24
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Andover Manor Rehab And Nursing during CMS and state inspections, most recent first.
The facility failed to provide a dignified dining experience for residents in the dementia care unit, with significant delays in meal service during breakfast and lunch. Observations showed gaps of six to seventeen minutes between residents at the same table receiving their meals, leading to undignified situations such as a resident attempting to feed a table mate. A nurse described the mealtime tray pass as chaotic, with insufficient staff support.
The facility failed to implement and develop comprehensive care plans for several residents, leading to deficiencies in care. One resident did not receive compression socks as ordered, another's heels were not offloaded despite being at high risk for pressure ulcers, and comprehensive care plans were missing for residents with pacemakers, skin-picking behaviors, and substance abuse histories. Staff interviews revealed a lack of adherence to care plans and awareness of specific resident needs.
The facility failed to meet professional standards for three residents. A resident used an air mattress without a physician's order, another received unnecessary treatment for a non-existent wound, and a third did not receive timely antibiotic administration due to pharmacy delays without notifying the NP/MD.
A facility failed to ensure consistent documentation of Advance Directives for a resident with severe cognitive impairments. The resident's MDS indicated a DNR and DNI status, but a physician order conflicted with this by indicating a FULL CODE status. Interviews with staff revealed acknowledgment of the discrepancy, emphasizing the need for matching documentation to ensure clarity on the resident's code status.
The facility failed to maintain confidentiality of residents' medical records when two nurses left computer screens on medication carts unlocked, exposing sensitive information. Despite being aware of the requirement to lock screens, both nurses left them unattended, leading to a breach of patient confidentiality.
A resident with dementia and a history of wandering approached another resident, leading to an altercation where one resident pinched the other's cheek. The incident occurred during an activity session with insufficient staff supervision, highlighting a failure to prevent resident-to-resident abuse as per facility policy.
A resident with a history of wandering approached another resident, leading to an altercation where the latter pinched the former's cheek, causing redness and pain. Despite facility policy requiring immediate reporting of such incidents, the event was not reported to the state agency. The incident occurred during an activity session with insufficient supervision.
A facility failed to complete a Significant Change in Status Assessment (SCSA) in a timely manner for a resident admitted to hospice services. The resident, with severe cognitive impairment and other medical conditions, was admitted to hospice, but the required SCSA was not completed within the mandated timeframe. Both the MDS coordinator and the DON acknowledged the oversight.
A facility failed to accurately assess a resident's range of motion in the MDS, despite observations and staff interviews indicating limited mobility in the resident's left arm and hand. The resident, diagnosed with Alzheimer's, muscle weakness, and multiple sclerosis, was observed with their left arm contracted, contradicting the MDS assessments. Staff confirmed the resident's dependency on care and impaired mobility, which was not documented in the MDS.
A facility failed to create a baseline care plan for a resident requiring psychotropic medications, leading to a deficiency. The resident, with anxiety disorder, adjustment disorder, and dementia, showed severely impaired cognition and was dependent on self-care. Despite physician orders for Olanzapine and Diazepam, no baseline care plan was documented. The DON confirmed that a care plan should have been established upon admission.
The facility failed to update care plans for two residents regarding hospice services. One resident's care plan was not revised to include hospice services after admission to hospice care, while another resident's care plan was not updated to reflect the discontinuation of hospice services. Interviews with staff confirmed the expectation for care plans to accurately reflect residents' current care status.
A facility failed to ensure interdisciplinary team participation in the discharge planning process for a resident with severe cognitive impairment and multiple health conditions. Despite an active order for discharge, the medical record lacked documentation of the discharge plan, including input from the resident or responsible parties. Interviews revealed a lack of coordination and documentation among staff, leading to the deficiency.
The facility failed to assist two residents with meals as per their care plans. One resident with severe cognitive impairments was left to feed themselves without staff support, despite needing substantial assistance. Another resident, also with cognitive impairments and requiring a mechanically altered diet, was observed with meal trays left within reach but without necessary supervision or assistance. Staff interviews confirmed the residents' needs for meal assistance, which were not consistently met.
A resident at high risk for pressure ulcers was found with an air mattress set incorrectly at the firmest setting, contrary to the physician's order. Despite multiple observations and staff interviews, the mattress remained improperly set, indicating a failure in monitoring and equipment management.
A facility failed to assess the necessity of an indwelling catheter for a resident admitted with dementia, heart failure, and diabetes. The resident had a catheter inserted due to urinary retention during a hospital stay, with a recommendation for a urology consult that was not documented. The care plan indicated catheter use for a healed sacral ulcer and urinary retention, but no approved diagnosis justified its continued use. Staff interviews revealed that a voiding trial should have been conducted, which was not done.
The facility failed to provide sufficient staff during the breakfast meal on the A3 unit, resulting in inadequate assistance for residents who required help with eating. Observations showed that several residents were left without assistance, and their meals were left untouched for extended periods. Interviews with staff confirmed that the staffing levels were insufficient to meet the needs of the residents, with the unit often being staffed with only three CNAs instead of the scheduled four.
A facility failed to provide necessary behavioral health care for a resident with severe cognitive impairments and multiple diagnoses, including dementia and anxiety. Despite a physician's recommendation for a psychiatric consult in December, the resident had not been seen by psychiatric services by January, as confirmed by staff interviews and medical record reviews.
The facility failed to serve meals at an appetizing temperature, as observed during a breakfast service where residents in the Florida room experienced delays in meal delivery. CNAs reported that the last resident was served very late with cold food. A test tray showed pancakes at 90°F and sausage at 80°F, both barely warm. The Food Service Director expected meals to be hot and palatable.
The facility did not adequately offer snacks between meals, as observed during a survey. Some residents reported not being offered snacks after dinner and were unaware of their availability. Although snacks were available in kitchenettes, a CNA stated they were only given upon request, with no routine evening offering. The DON and Administrator acknowledged the expectation for snacks to be offered, but the Administrator was unaware this was not happening.
The facility failed to accurately document blood pressure readings for two residents with orders to avoid using the left arm due to mastectomy. Despite physician orders, records showed blood pressure was documented as taken from the left arm, and care plans did not reflect this restriction. Interviews confirmed the documentation errors.
Undignified Dining Experience in Dementia Care Unit
Penalty
Summary
The facility failed to provide a dignified dining experience for residents in the dementia care unit, as observed during breakfast and lunch meal services. The facility's policy, revised on November 5, 2024, mandates regular audits of the food services department to ensure a safe and pleasant dining experience. However, during breakfast, there were significant delays in serving meals to residents at the same table, with gaps ranging from six to thirteen minutes between the first and last resident receiving their meals. This delay was also observed during lunch, with gaps of ten to seventeen minutes. These delays led to situations where residents were left waiting for their meals, and in one instance, a resident attempted to feed a table mate. During an interview, Nurse #9 described the mealtime tray pass as chaotic, noting that staff did not receive assistance from other floors or departments. The nurse emphasized that meals should be served in order to prevent residents from waiting unnecessarily. The observations and interview indicate a failure to adhere to the facility's policy, resulting in an undignified dining experience for residents in the dementia care unit.
Failure to Implement and Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for five residents, leading to deficiencies in their care. For one resident with chronic obstructive pulmonary disease and edema, the facility did not implement the use of compression socks as ordered by the physician. Despite the resident's dependence on staff for lower body dressing and the presence of a blister on the heel, there was no documentation explaining the absence of compression socks, and staff interviews revealed a lack of adherence to the care plan. Another resident, who was at high risk for pressure ulcers due to severe cognitive impairment, was observed multiple times with heels flat on the mattress, contrary to the care plan directive to offload heels while in bed. Staff interviews confirmed the expectation to follow the care plan, yet the resident's heels were not offloaded as required, indicating a failure to implement the care plan effectively. Additionally, the facility did not develop comprehensive care plans for residents with specific needs, such as a pacemaker care plan for a resident with severe cognitive impairments, a behavior care plan for a resident with a history of skin picking and hallucinations, and a substance abuse care plan for a resident with a history of alcohol abuse. Interviews with staff, including nurses and social workers, highlighted a lack of awareness and documentation regarding these residents' specific care needs, further contributing to the deficiencies.
Failure to Adhere to Professional Standards of Practice
Penalty
Summary
The facility failed to meet professional standards of practice for three residents. For Resident #19, the facility did not obtain a physician's order for the use of an air mattress, which was observed in use during a survey. Both Nurse #1 and the Director of Nursing acknowledged that a physician's order should have been in place for the air mattress. For Resident #69, the facility continued a treatment for a right ankle wound that was not present. Despite the absence of any open skin areas, as confirmed by a weekly skin check and direct observation, the treatment order remained active. Nurse #7 and Unit Manager #1 were unaware of any current wounds, and the order's origin was unclear, indicating a lapse in communication and documentation. Resident #106 did not receive timely administration of an antibiotic due to the medication not being delivered by the pharmacy. The progress notes did not indicate that the physician or nurse practitioner was notified of the delay, contrary to the facility's policy. Nurse #6 and the Director of Nursing confirmed that the NP/MD should have been informed about the medication not being administered as ordered.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were consistently documented in the medical record for a resident with severe cognitive impairments. The resident, admitted in February 2024, had diagnoses including dementia, adult failure to thrive, and anxiety. The resident's Minimum Data Set (MDS) indicated a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status. However, a physician order dated May 2024 indicated a FULL CODE status, conflicting with the resident's Medical Orders for Life Sustaining Treatment (MOLST) dated August 2024, which confirmed a DNR and DNI status. During interviews, Nurse #3 and the Director of Nurses (DON) acknowledged the discrepancy between the MOLST and the physician order, emphasizing that they should match to ensure clarity on the resident's code status. This inconsistency in documentation could lead to confusion among the nursing staff regarding the resident's end-of-life care preferences, as highlighted by the interviews conducted during the survey.
Failure to Maintain Confidentiality of Medical Records
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records on one of the three resident units. This deficiency was observed when Nurse #10 and Nurse #11 left the computer screens on the medication carts unlocked, exposing residents' medical and private information. On two separate occasions, Nurse #10 walked away from the medication cart without locking the computer screen, leaving it unattended and revealing sensitive information. Similarly, Nurse #11 was observed leaving the computer screen unlocked while walking away to the medication room and a resident's room. Interviews with the involved nurses confirmed that they were aware of the requirement to lock the computer screens to protect resident information. Nurse #11 acknowledged that she should lock the screen when leaving the medication cart, and Nurse #10 confirmed that the computer should always be locked if unattended. The Director of Nurses also stated that she expects nurses to lock the computer screens to ensure the confidentiality of residents' medical records. Despite this expectation, the failure to secure the computer screens resulted in a breach of patient confidentiality.
Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a resident-to-resident altercation involving two residents, one of whom pinched the other's cheek. Resident #56, who has dementia with behavioral disturbance and a history of wandering and encroaching on others' personal space, approached Resident #23, who also has dementia with psychotic features and behavioral disturbance. Resident #23 reacted aggressively by pinching Resident #56's cheek, causing redness and pain. The incident occurred during an activity session where only one staff member, Activity Assistant #3, was present. The assistant was engaged with other residents and did not notice Resident #56 approaching Resident #23 until the altercation occurred. The assistant had to intervene by separating the residents and escorting them to different areas. Both the Activity Assistant and Nurse #12 acknowledged that Resident #56 requires close supervision due to their behavior history. Interviews with staff, including the Unit Manager and Director of Nurses, revealed that the incident was considered physical abuse due to the infliction of pain. However, the Director of Nurses later determined that the incident was not abusive after using a navigation tool to assess the situation. Despite this, the facility's policy requires staff to monitor and prevent such altercations, which was not adequately done in this case.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency within the mandated timeframes following a resident-to-resident altercation. Specifically, the incident involved Resident #23 pinching Resident #56, which was not reported to the state agency as required. The facility's policy mandates that such incidents be reported within two hours, but this was not adhered to in this case. Resident #56, who has a history of wandering and getting close to other residents, approached Resident #23 and moved close to their face, prompting Resident #23 to react aggressively by pinching Resident #56's cheek. This resulted in redness and pain for Resident #56. Both residents have cognitive impairments, with Resident #56 having dementia with behavioral disturbance and Resident #23 having dementia with psychotic features and behavioral disturbance. The incident occurred during an activity session where supervision was insufficient, as noted by Activity Assistant #3, who was the only staff present. Despite the facility's policy and a flyer titled 'Abuse Reporting' indicating the need for immediate reporting of such incidents, the Director of Nurses decided not to report the incident to the state agency, believing it did not meet the criteria for reportable abuse. This decision was made despite the clear expectation from the facility's policy and staff interviews that such incidents should be reported promptly.
Failure to Complete Timely SCSA for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) in a timely manner for a resident who was admitted to hospice services. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, a SCSA is required when a resident enrolls in a hospice program, and it must be completed by the 14th calendar day after the assessment reference date (ARD). In this case, the resident was admitted to hospice services on December 2, 2024, but the SCSA was not completed by the required date of December 30, 2024, and remained incomplete as of January 7, 2025. The resident involved had a history of traumatic subdural hemorrhage, diabetes, and dysphagia requiring tube feedings, and was assessed to have severe cognitive impairment. During interviews, both the MDS coordinator and the Director of Nurses acknowledged that the SCSA should have been completed within the specified timeframe following the resident's admission to hospice services. This oversight represents a failure to adhere to the required assessment protocols for residents experiencing significant changes in their health status.
Inaccurate MDS Assessment of Resident's Range of Motion
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's condition, specifically regarding the Minimum Data Set (MDS) for a resident with Alzheimer's disease, muscle weakness, and multiple sclerosis. The MDS inaccurately reported that the resident had no functional limitation in the range of motion (ROM) in their extremities, despite observations and staff interviews indicating otherwise. The resident was observed with their left arm pulled across their chest and fingers contracted into a fist, suggesting a limitation in ROM that was not documented in the MDS assessments dated September and December 2024. Interviews with staff and a family member confirmed that the resident had impaired mobility in their left arm and hand, which had been present for some time. Certified Nursing Assistants and nurses reported the resident's dependency on care and inability to use their left arm and hand due to contraction. The MDS nurse acknowledged that the impaired ROM was present at the time the December 2024 MDS was completed and should have been accurately reflected in the assessment. This discrepancy between the MDS documentation and the resident's actual condition constitutes a deficiency in the facility's assessment process.
Failure to Develop Baseline Care Plan for Psychotropic Medications
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who requires psychotropic medications, resulting in a deficiency. The resident, admitted in January 2024, has diagnoses including anxiety disorder, adjustment disorder, and dementia, and scored a 3 out of 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The resident is dependent on self-care activities and exhibits behaviors that impact care delivery. Physician orders for the resident included Olanzapine and Diazepam for psychotic disorder and anxiety, respectively. However, a review of the medical record revealed that a baseline care plan for these psychotropic medications was not created. During an interview, the Director of Nursing acknowledged that such a care plan should have been developed upon admission.
Failure to Update Care Plans for Hospice Services
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were reviewed and revised by the interdisciplinary team following significant changes in their care status. For one resident, the facility did not update the care plan to include hospice services after the resident was admitted to hospice care. The resident, who was admitted in March 2024 with conditions such as traumatic subdural hemorrhage, diabetes, and dysphagia, was receiving hospice services as of December 2, 2024. However, the hospice care plan was not included in the resident's active plan of care until January 7, 2025, after the surveyor inquired about it. Interviews with the MDS nurse and the Director of Nursing confirmed that they expected a hospice care plan to be in place for residents receiving such services. For another resident, the facility failed to update the care plan after the discontinuation of hospice services. This resident, admitted in October 2021 with diagnoses including epilepsy, chronic obstructive pulmonary disease, and Alzheimer's disease, was discharged from hospice care on April 27, 2024. Despite this, the hospice care plan remained active for over eight months, even after two quarterly MDS assessments. Interviews with a nurse and the Unit Manager revealed that the resident had been off hospice services for some time, and the care plan should not have indicated ongoing hospice care. The Unit Manager acknowledged that the care plan should have been updated to reflect the resident's current status.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to ensure that the interdisciplinary team participated in the discharge planning process for a resident with severe cognitive impairment and multiple health conditions, including memory deficit following cerebral infarction, type 2 diabetes mellitus with diabetic neuropathy, and bipolar disorder. The facility's policy requires a post-discharge plan to be developed by the care plan team with the assistance of the resident or their family, but this was not adhered to in the case of the resident. The resident's care plans indicated no plans for discharge, yet there was an active physician's order for discharge home with services and medications. The medical record lacked documentation of the discharge planning process, including the resident or responsible parties' input, and failed to specify the agency or contact information for services post-discharge. Interviews with facility staff revealed a lack of coordination and documentation regarding the discharge process. The Administrator believed the discharge was planned with the PACE program, but there was no documentation to support this in the resident's medical record. The Director of Nursing expected the facility's social worker to document the discharge planning, but this was not done. Additionally, Nurse #15 confirmed that there was no nursing discharge assessment or progress note indicating the resident's discharge. This lack of documentation and coordination among the care team members led to the deficiency in the discharge planning process for the resident.
Failure to Assist Residents with Meals
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for two residents, specifically in the area of meal assistance. Resident #94, who was admitted with diagnoses including dementia and adult failure to thrive, was observed on multiple occasions without the required assistance during meal times. Despite having severe cognitive impairments and a care plan indicating the need for substantial assistance with eating, Resident #94 was left to attempt feeding themselves without staff support. Interviews with nursing staff confirmed that the resident required assistance during meals, yet this was not consistently provided. Similarly, Resident #26, who has severe cognitive impairments and requires a mechanically altered diet, was observed multiple times with meal trays left within reach but without the necessary supervision or assistance. The resident's care plan indicated a need for partial assistance with eating, yet staff were not present to provide this support. Interviews with staff, including a Speech Language Pathologist and a CNA, acknowledged the resident's need for meal setup and occasional assistance, but these needs were not met as per the care plan.
Failure to Ensure Proper Functioning of Pressure-Relieving Mattress
Penalty
Summary
The facility failed to adhere to professional standards of care for the prevention of pressure ulcers for a resident who was assessed as being at high risk for developing pressure ulcers. The resident, who has a history of pressure wounds and severe cognitive impairment, was dependent on staff for all aspects of care. Despite the physician's order for a pressure-redistribution mattress to be set at a specific setting, the air mattress was consistently observed to be set at the highest, firm setting, contrary to the medical plan of care. Multiple observations over several days showed that the air mattress was not functioning as intended, as it was blinking at the highest setting instead of being set to the prescribed level. Interviews with nursing staff and the unit manager confirmed that the mattress should have been set to a lower setting as per the physician's order. The unit manager attempted to adjust the mattress but was unable to set it correctly, indicating a failure in monitoring and ensuring the proper functioning of the equipment, which is crucial for the resident's care.
Failure to Assess Indwelling Catheter Necessity
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling catheter was assessed for its removal as soon as possible, unless the resident's clinical condition demonstrated a continued need for catheter use. The resident, who was admitted in August 2023 with diagnoses including dementia, heart failure, and diabetes, had an indwelling catheter inserted due to urinary retention during a hospital stay from August 2 to August 14, 2023. The hospital paperwork recommended a urology consult, which was not documented in the resident's medical record. The resident's care plan, updated in January 2025, indicated the presence of an indwelling Foley catheter for a history of unstageable sacrum region pressure and urinary retention. However, the resident's medical history and diagnosis lists did not indicate a diagnosis justifying the continued use of the catheter. Interviews with facility staff revealed that a resident with an indwelling catheter without an approved diagnosis should undergo a voiding trial, which was not conducted for this resident. Additionally, the sacral ulcer had healed in June 2024, further questioning the necessity of the catheter.
Inadequate Staffing During Breakfast Meal
Penalty
Summary
The facility failed to ensure sufficient staffing during the breakfast meal on the A3 unit, which resulted in inadequate assistance for residents who required help with eating. Observations on January 6, 2024, revealed that there were only two staff members present in the dining room initially, with one staff member being a nurse who remained with a single resident throughout the meal. Several residents were left without assistance, and their meals were left untouched for extended periods. At one point, a resident who required one-on-one assistance attempted to eat a napkin, highlighting the lack of adequate supervision and assistance. Interviews with staff members, including CNAs and nurses, confirmed that the staffing levels were insufficient to meet the needs of the residents in the Florida room, where all residents required some form of assistance with eating. The working schedule review indicated that on multiple occasions, the unit was staffed with only three CNAs instead of the scheduled four, contributing to the inability to provide timely assistance to all residents. The deficiency was acknowledged by the facility's administrator during a Quality Assurance and Performance Improvement review.
Failure to Provide Timely Psychiatric Consultation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident, identified as Resident #70, who was admitted with diagnoses including dementia with behaviors, restlessness, agitation, delirium, and insomnia. The resident's Minimum Data Set (MDS) indicated severe cognitive impairments, and the resident was receiving antidepressant and antianxiety medications. A physician's order from September 2024 included Counseling and Psychology Services as needed, and a progress note from December 2024 suggested the resident might benefit from an SSRI and a referral to psychiatry. However, the facility did not ensure that a psychiatric consult was completed. Interviews with facility staff revealed that the nursing staff was responsible for notifying the psychiatric provider when a resident needed to be seen, and psychiatric services were available weekly. Despite this, the resident had not been seen by psychiatric services by January 2025, as confirmed by the absence of a note in the medical record. The Director of Nurses acknowledged that the resident should have been seen by psychiatric services following the physician's recommendation in December 2024.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to provide meals that were palatable and served at an appetizing temperature, as observed during a breakfast meal service on the A3 unit. Twelve residents were present in the Florida room, all requiring assistance or being dependent on staff to eat. The first resident received their meal at 9:10 A.M., while the last resident was served at 9:43 A.M., resulting in a 43-minute delay. Certified Nursing Assistants (CNAs) reported that the last resident was served very late and the food was not warmed up. During a Resident Council Meeting, all ten residents reported that their meals were cold upon delivery. Further observations on a subsequent day revealed that the second food truck arrived at the A3 unit at 8:57 A.M., and a test tray was received at 9:15 A.M. The pancakes on the test tray registered at 90 degrees Fahrenheit and were barely warm, while the sausage patty registered at 80 degrees Fahrenheit and was also barely warm with a small hard piece. The Food Service Director acknowledged that she would expect food to be hot and palatable for residents and delivered in a timely manner.
Failure to Offer Snacks Between Meals
Penalty
Summary
The facility failed to provide or offer adequate snacks between meals, as observed during a survey. During a resident group meeting, half of the residents who could not independently obtain snacks reported not being offered snacks after dinner and were unaware of their availability. Observations confirmed that kitchenettes on all units had a variety of snacks available. However, a CNA stated that snacks were only given upon request, and there was no routine offering of snacks in the evening. The Director of Nursing and Administrator acknowledged that residents should be offered snacks between meals and that there should be a snack pass in the evening, but the Administrator was unaware that this was not occurring.
Inaccurate Blood Pressure Documentation for Residents with Mastectomy
Penalty
Summary
The facility failed to ensure accurate documentation of blood pressure readings for two residents, both of whom had medical orders specifying that blood pressure should not be taken on their left arms due to a history of mastectomy. Resident #2, who was admitted with chronic heart failure, chronic respiratory failure, diabetes, and hypertension, had a physician order dated 9/9/21 indicating no blood pressure should be taken on the left arm. However, multiple entries in the resident's medical record inaccurately documented blood pressure readings as being taken from the left arm. The resident's care plan also failed to include the restriction on taking blood pressure from the left arm. Similarly, Resident #19, admitted with traumatic subdural hemorrhage, diabetes, and hypertension, had a physician order dated 3/25/24 specifying that blood pressure should only be taken from the right arm due to a left mastectomy. Despite this, the resident's medical records showed several instances where blood pressure was documented as being taken from the left arm. The care plan for Resident #19 also did not reflect the restriction on using the left arm for blood pressure measurements. Interviews with nursing staff and the Director of Nurses confirmed that the documentation was incorrect and did not adhere to the physician's orders.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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