Care Village At Parkway
Inspection history, citations, penalties and survey trends for this long-term care facility in Boston, Massachusetts.
- Location
- 1190 Vfw Parkway, Boston, Massachusetts 02132
- CMS Provider Number
- 225497
- Inspections on file
- 29
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Care Village At Parkway during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple medical conditions was found with a bed sheet wrapped around the chest and tied behind a wheelchair by a CNA, with approval and direct involvement from a nurse, to prevent slipping or getting up. Surveillance footage confirmed the restraint was applied and reapplied by staff, contrary to facility policy prohibiting such restraints except for medical necessity. The incident was discovered and reported by housekeeping staff.
A resident in an LTC facility received 40 units of Levemir insulin in error due to improper identification by the DON, who was unfamiliar with the residents and relied on a CNA for assistance. The resident, who was not prescribed insulin, was transferred to the hospital for monitoring. The facility's policy of using two methods for resident identification before medication administration was not followed.
The facility failed to ensure a dignified dining experience for residents dependent on staff for meal assistance. Two residents with severe cognitive impairments were left with meal trays not set up for consumption and without staff assistance. Staff behavior further compromised dignity, with inappropriate references to residents and improper seating during assistance. In the dining room, delays in serving meals led to residents taking food from others' trays without staff intervention.
The facility failed to provide a homelike dining environment in three nursing units, where residents were observed eating meals on trays, some of which were chipped. Staff interviews revealed that trays were not removed as per policy, with new CNAs unfamiliar with procedures contributing to the oversight.
The facility failed to provide an adequate activities program for residents on one unit, with multiple observations of residents sitting unengaged in the dining room. Several residents expressed boredom and a lack of invitations to activities. Staff interviews revealed the absence of an activities director and insufficient staff to manage activities, resulting in scheduled activities not occurring and residents lacking engagement.
The facility did not complete annual performance reviews for three CNAs as required. A review of their employment records showed the evaluations were missing, and the Regional Administrator acknowledged that these evaluations should have been conducted.
The facility failed to properly label and date medications on one nursing unit. A surveyor found an opened inhaler of Budesonide and Formoterol Fumarate Dihydrate and an Albuterol Sulfate inhaler without labels indicating the resident's name, date opened, or expiration date. The facility's policy requires such labeling, but it was not adhered to, as confirmed by a unit manager.
A resident with a history of stroke and dysphagia did not receive necessary dental services, including routine cleaning and denture replacement. Despite being cognitively intact and expressing a desire for dental care, there was no record of consent or discussions about dental visits. Facility staff were unaware of the resident's dental needs, and documentation was inconsistent, failing to adhere to the facility's policy on dental services.
The facility failed to properly store food items and maintain meal trays and domes in good condition, risking foodborne illness. Staff's personal food was stored with resident food, and items were unlabeled and undated. Meal trays were chipped, exposing metal, and domes were worn and rough. The Food Service Director acknowledged these issues.
The facility failed to implement an effective pest control program, as residents reported persistent pest issues despite weekly exterminator visits. Pest control logs documented ongoing rodent and cockroach activity, with structural deficiencies like gaps in floor tiles and broken cabinetry unaddressed. Surveyor observations confirmed these issues, highlighting a disconnect between pest control documentation and actual repairs.
The facility failed to ensure that two residents had their call lights within reach, violating its policy. One resident with stroke and hemiplegia and another with dementia and diabetes were found with call lights out of reach, despite being cognitively intact. Staff interviews confirmed that call lights should always be accessible to residents.
A facility failed to ensure a resident's Advance Directives were validly documented. The resident, with severe cognitive impairments, had a MOLST form indicating DNR/DNI status, but it lacked a necessary signature from the resident or Health Care Proxy, rendering it invalid. Staff confirmed that verbal consent is insufficient, and the form should have been signed and returned.
A facility failed to ensure an accurate MDS assessment for a resident discharged with diagnoses including cervical disc disorder and monoplegia. The resident's discharge MDS was incorrectly coded as a planned discharge to a hospital, while the resident was actually discharged home. This error was confirmed by the MDS Nurse.
A facility failed to request a PASARR Level I for a resident with a Serious Mental Illness (SMI) who exceeded the 30-day discharge exception. The resident, diagnosed with bipolar disorder, was initially expected to stay for less than 30 days but remained longer. The facility did not submit the required PASARR to the DMH by the 28th day, and the medical record lacked documentation of this submission. The social worker acknowledged the oversight during interviews.
The facility failed to implement physician orders for several residents, including not obtaining monthly weights, lacking orders for dressings and RN pronouncements of death, and discharging residents without physician orders. These oversights were confirmed by staff interviews.
A resident with severe cognitive impairment and dysphagia was left unsupervised during meals, contrary to their care plan and facility policy. Observations showed the resident eating alone, resulting in food spillage and wet coughs. Staff interviews confirmed the need for continuous supervision to prevent aspiration and provide assistance, which was not provided.
A facility failed to identify and document skin conditions on a resident's shins, despite observations of a dark red area and bruising. The resident, with a history of subdural hemorrhage and other conditions, had a dressing on the left shin without a physician's order. A nurse admitted to not noting these conditions during a skin check, and no skin incident report was completed, leading to a deficiency in care.
A resident with sensorineural hearing loss and moderate cognitive impairment was not provided with necessary hearing aids, as required by physician orders. Despite being admitted with hearing aids, staff interviews revealed they were missing, and the resident was not observed wearing them during the survey. The ADON confirmed the hearing aids were lost and should have been documented and replaced.
A resident at risk for pressure ulcers was not wearing Prevalon boots as ordered, leading to a deficiency in care. The resident, with severe cognitive impairment and a history of pressure ulcers, was observed with heels directly on the mattress. Despite clear orders and care plans, there was no documentation of refusal or removal of the boots, as confirmed by nursing staff.
A resident with diabetes and other health conditions did not receive proper foot care, as their toenails were observed to be long, thick, and curling. Despite orders for daily diabetic foot care, the facility failed to document the condition of the toenails or notify the doctor. Observations and records indicated a lack of adherence to the facility's policy and physician's orders.
A resident with a left hand contracture was not using a prescribed hand carrot orthotic, as observed by a surveyor. Despite physician orders and a care plan requiring its use for contracture prevention, the orthotic was not present in the resident's room, and there was no documentation of refusal. Interviews with facility staff confirmed the resident should have been using the orthotic, highlighting a deficiency in care implementation.
The facility failed to investigate falls and incidents for two residents, leading to deficiencies in accident hazard prevention. A resident with multiple sclerosis fell in the smoking area, but no post-fall investigation was initiated despite staff being informed. Another resident got their hand caught in an elevator, but no incident report or investigation was conducted. The lack of investigation and reporting was acknowledged by facility staff.
A facility failed to provide proper respiratory care for three residents. One resident's nebulizer equipment was not maintained according to policy, with the mask unbagged and tubing undated. Another resident's oxygen flow rate exceeded physician orders, and staff were aware of self-adjustments but did not monitor effectively. A third resident received oxygen at a higher rate than prescribed, and their BiPAP mask was found dirty, indicating a lack of adherence to cleaning protocols.
The facility failed to provide necessary behavioral health care for two residents. One resident with a history of Substance Use Disorder did not have an individualized care plan, and another resident with dementia did not receive recommended medication for anxiety and agitation. The facility did not implement the Psychiatric Nurse Practitioner's recommendations, leading to deficiencies in care.
A resident with multiple diagnoses, including COPD and depression, was incorrectly prescribed Sertraline for COPD symptoms. The pharmacy reviewed the order but failed to identify the error, as the medication was intended for depression. Interviews with staff confirmed the prescription was incorrect, leading to a deficiency.
A facility failed to ensure a resident was free from unnecessary medications by not including a stop and re-assessment date for a PRN Ativan order. The resident, with severe cognitive impairments and multiple diagnoses, was prescribed Ativan for anxiety without proper reassessment protocols, as confirmed by staff interviews.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. One resident with hearing loss was not wearing hearing aids as documented, and the aids were reportedly lost. Another resident with a hand contracture was not using a prescribed splint, despite documentation indicating otherwise. Staff interviews confirmed these discrepancies, highlighting a failure in documentation practices and adherence to physician orders.
The facility failed to post daily nurse staffing information as required. During a survey, the surveyor could not find the staffing posting. An observation and interview revealed that the Appointment Coordinator found an empty frame meant for the staffing information. The current Scheduler admitted to not posting the staffing information since starting work a few months ago.
The facility failed to maintain accurate medical records for two residents when Health Care Proxy (HCP) activation forms were completed without corresponding HCP forms or designated Health Care Agents (HCA) on file. The Medical Director was not informed of the missing documentation, and the Director of Nurses admitted to not reviewing the records for HCP and HCA designations.
The facility failed to serve the menu as planned for a breakfast meal. The cook served mixed fruit and a muffin instead of the listed items, which included a 4oz yogurt. The cook admitted to running out of yogurt and did not make a substitution. The Food Service Director was unaware of the shortage and expected staff to inform him for an approved substitution.
The facility failed to inform two residents of their right to be informed about the use of psychotropic medications. Both residents were found to be taking Seroquel without documented consent, despite the facility's policy requiring informed written consent. Interviews with staff revealed gaps in the process for obtaining and documenting these consents.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. One resident with quadriplegia was observed multiple times with heels directly on the mattress despite orders to offload heels. Another resident with severe cognitive impairment was not wearing Prevalon boots as ordered. Staff confirmed the orders were not followed.
The facility failed to provide meaningful and person-centered group activities for residents, leaving them unengaged and without scheduled activities. The facility has been without an activities director since December, relying on volunteers and other staff to fill in, which has proven insufficient.
The facility failed to maintain visible and accessible emergency equipment supplies at the bedside for a resident with End Stage Renal Disease, despite the care plan requiring it. Observations confirmed the absence of these supplies, which are crucial for managing emergencies such as bleeding from the fistula site.
A nurse made five medication errors in 28 opportunities, resulting in a 17.86% error rate. Errors included administering bedtime medications in the morning and failing to check blood pressure before giving metoprolol tartrate. The DON confirmed that nurses should follow the five rights of medication administration and check parameters as required.
The facility failed to ensure that medications were labeled and stored according to the manufacturer's guidelines on one of three sampled medication carts. Several medications, including eye drops, insulin pens, and liquid protein, were found opened and undated, contrary to the facility's policy and State and Federal laws.
The facility failed to follow a therapeutic diet as prescribed by the attending physician for a resident with a 1-liter fluid restriction. Observations revealed that the resident was consistently provided with more fluids than prescribed during meals, and the diet slips did not indicate the fluid restriction. Interviews with staff indicated a lack of awareness and communication regarding the resident's fluid restriction.
The facility failed to ensure complete and accurate medical record documentation for two residents. One resident's wound treatments were not properly documented, and another resident's use of Prevalon boots was inaccurately recorded despite observations showing the boots were not worn.
The facility failed to ensure a gap in a resident's bed was filled to prevent possible entrapment. Despite the facility's policy requiring the space between the mattress and the footboard to be filled, observations revealed a large gap with the foam bolster intended to fill it placed on the bedside dresser. Interviews with staff confirmed the bolster should have been in place to prevent entrapment.
Improper Use of Physical Restraint on Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure a resident was free from the use of physical restraints, except as required for medical treatment. The incident involved a resident with Alzheimer's disease, parkinsonism, acute kidney failure, and a history of cerebrovascular accident with right-sided hemiplegia, who was cognitively impaired and non-ambulatory at the time, with a cast on the right lower leg. On the overnight shift, the resident was placed in a wheelchair and positioned in the dayroom by a CNA, who, after consulting with a nurse, wrapped a bed sheet around the resident's chest, under the arms, and tied it behind the wheelchair to prevent the resident from getting up or slipping forward. Surveillance footage confirmed that the CNA initially wrapped the sheet around the resident and that the nurse approved the action by nodding. When the resident removed the sheet, the nurse reapplied and secured it to the wheelchair. The resident remained calm and showed no signs of distress during the incident. The restraint was discovered by a housekeeper, who reported it to the housekeeping supervisor, who in turn notified the nurse. The nurse then removed the sheet from the resident's wheelchair. Interviews with staff revealed that the CNA believed the use of the sheet was approved by the nurse and did not consider it a restraint, as the intention was to keep the resident safe from slipping. However, the facility's policy clearly prohibits the use of physical restraints for discipline or convenience and requires systematic evaluation and monitoring of any device that could constitute a restraint. The nurse later denied knowledge of the sheet, but this was contradicted by the video evidence showing her involvement in both approving and reapplying the restraint.
Medication Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the Director of Nursing (DON) administered 40 units of Levemir insulin to the wrong resident. The error occurred because the DON did not properly identify the resident before administering the medication. The resident who received the insulin in error was not prescribed insulin and was only on Metformin for diabetes management. This resident was subsequently transferred to the hospital for evaluation and admitted to the Intensive Care Unit for close monitoring of blood sugar levels. The incident was reported through the Health Care Facility Reporting System, and it was noted that the DON was unfamiliar with the residents on the unit and relied on a Certified Nurse Aide (CNA) to identify the residents. The DON admitted to not checking the resident's photo on the Medication Administration Record (MAR) before administering the insulin. The resident who was supposed to receive the insulin was in their room, while the resident who received it in error was in the dining room at the time of administration. Interviews with staff revealed that the DON was covering a shift due to a lack of nursing coverage and was not familiar with the residents. The DON asked CNAs for assistance in identifying residents but did not verify the identity of the resident who received the insulin. The facility's policy requires that residents be identified using two methods before medication administration, which was not followed in this case.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents who were dependent on staff for assistance with meals. Resident #56, who had severe cognitive impairments and was dependent on staff for eating, was observed with meal trays left within reach but not set up for consumption, with no staff present to assist. This was despite care plans indicating the need for total assistance and supervision to prevent choking. Similarly, Resident #66, also with severe cognitive impairments and dependent on staff for eating, was left with meal trays not set up for consumption and without staff assistance, even as staff were observed collecting other residents' trays. On the [NAME] 2 and China Garden 1 units, staff behavior further compromised the dignity of residents during meal times. A nurse was overheard referring to residents as "feeders," and staff were observed assisting residents with meals while standing or sitting on the armrest of a chair, rather than at the residents' level. These actions were contrary to the facility's policy on dignity and quality of life, which emphasizes treating residents with respect and individuality. In the China Garden 2 dining room, the dining experience was further compromised by delays in serving meals, leading to residents taking food and drinks from others' trays. One resident, who was consistently served last, was observed signaling for food and consuming items from other residents' trays while staff did not intervene. Interviews with staff indicated awareness of these issues, yet the necessary supervision and timely service were not provided, resulting in a lack of dignified dining experiences for the residents involved.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment for residents in three of its four nursing units, specifically on the [NAME] 1, China Garden 1, and China Garden 2 units. Observations by the surveyor revealed that residents were eating their meals on meal trays in the dining rooms, which is contrary to the facility's policy. On multiple occasions, residents were seen eating breakfast and lunch on meal trays, and some of these trays were chipped, further detracting from a homelike atmosphere. Interviews with staff, including CNAs and nurses, confirmed that the trays were not removed as per the facility's policy, with some staff attributing the oversight to new CNAs who were not yet familiar with the procedure. The deficiency was observed over two days, with specific instances noted where residents were served meals on trays that were not removed, as required. Staff interviews indicated a lack of adherence to the facility's policy, with some staff acknowledging that trays should be removed after meals are set up on the table. The use of chipped trays was also noted, which further compromised the quality of the dining experience for residents. The failure to remove meal trays and the use of chipped trays were consistent across the observed units, indicating a systemic issue in maintaining a homelike dining environment for residents.
Lack of Activities Program for Residents
Penalty
Summary
The facility failed to provide an adequate activities program for residents on the [NAME] 2 Unit, as observed during the survey. On multiple occasions, residents were found sitting in the dining room with the television on, but not engaged in any meaningful activities. The activity calendar did not list any group activities for certain days, and scheduled one-to-one visits were not conducted. Staff present in the room were observed completing documentation or sitting without interacting with the residents, and no activity staff were present to engage the residents. Several residents, including Resident #3, Resident #120, Resident #32, and Resident #52, were affected by the lack of activities. Resident #3, who has severe cognitive impairment, expressed boredom and a desire to participate in activities but was not informed of any. Resident #120, who is cognitively intact, also reported boredom and a lack of invitations to activities. Resident #32, who is legally blind, was found without the necessary equipment to listen to books on tape, which was a preferred activity. Resident #52, with severe cognitive impairment, was observed with no engagement or activity materials, despite having preferences for simple, structured activities. Interviews with staff revealed that the facility had been without an activities director for several months, and the Activity Assistant was unable to manage activities for all units alone. The Regional Administrator acknowledged the lack of an activities director and the need for staff to assist with activities. Despite the presence of an activity calendar, many scheduled activities did not occur, and residents were not provided with individualized activity materials or engagement, leading to increased feelings of boredom and isolation among the residents.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for three Certified Nursing Assistants (CNAs) as required. A review of the employment records for these CNAs revealed that the necessary evaluations were not completed. During an interview, the Regional Administrator confirmed that CNAs should receive annual performance evaluations, indicating a lapse in adherence to this requirement.
Improper Labeling and Dating of Medications
Penalty
Summary
The facility failed to ensure that medications were properly labeled and dated with an expiration date on one of its four nursing units. During an inspection, the surveyor observed that the medication cart on the [NAME] 2 nursing unit contained an opened and actively used aerosol inhaler of Budesonide and Formoterol Fumarate Dihydrate, which was not labeled with a resident's name or a date of opening or expiration. Additionally, an opened and actively used aerosol inhaler of Albuterol Sulfate was found without a date opened or expiration date. The facility's policy on the storage of medications requires that when the original seal of a manufacturer's container or vial is initially broken, the container or vial should be dated. The nurse is responsible for placing a date opened sticker on the medication and entering the date opened and the new date of expiration. However, this policy was not followed, as evidenced by the unlabeled inhalers. During an interview, Unit Manager #1 confirmed that prescription medications, including inhalers, should be labeled with the resident's name, the date opened, and the date of expiration.
Failure to Provide Dental Services and Denture Replacement
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services, including routine cleaning and denture replacement. The resident, who was admitted in November 2022 with conditions such as stroke, hemiplegia, and dysphagia, expressed a desire to see a dentist for a cleaning and to have missing top dentures replaced. Despite having a cognitive status indicating the resident was capable of making decisions, there was no record of consent for dental services or any documented discussions about dental visits. The resident's medical records and assessments were inconsistent, with earlier records indicating the presence of dentures and later assessments failing to mention them. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's dental needs. The Unit Manager and Assistant Director of Nursing acknowledged that consents for dental services should be obtained upon admission, but there was no evidence of this for the resident in question. The Assistant Director of Nursing was unable to locate the dentures or confirm if the resident had ever been seen by a dentist, highlighting a gap in the facility's adherence to its own policy on dental services and denture management.
Food Storage and Equipment Deficiencies
Penalty
Summary
The facility failed to properly store food items and maintain meal trays and domes in good condition, which could lead to foodborne illness. During an initial walk-through of the kitchen, surveyors observed staff's personal food items, including opened, unlabeled, and undated donuts, stored alongside resident food in the walk-in refrigerator. Additionally, a container of unlabeled, undated brown, congealed food and a container of red paste, identified as ketchup, were found without proper labeling or dating. The Food Service Director acknowledged that staff food should not be stored with resident food and that all food should be labeled and dated. During a lunch service observation, surveyors noted that numerous meal trays used for resident food were chipped and worn, with some exposing metal underneath the plastic coating. The meal domes covering residents' meals were also found to be very worn, scratched, and rough to the touch. The Food Service Director confirmed that meal trays and domes should be in good condition and not cracked or chipped, acknowledging the need for replacements.
Facility Fails to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by persistent pest issues reported by residents and documented by the pest control company. During a resident group interview, all participating residents reported the presence of mice, roaches, and fruit flies, despite weekly visits from an exterminator. The pest control logs revealed ongoing issues with rodent and cockroach activity, particularly in the kitchen and employee break rooms, and identified several structural deficiencies that were not addressed by the facility. The pest control company made several recommendations to address these issues, including repairing gaps in floor tiles, fixing broken cabinetry, and ensuring doors were rodent-proof. However, these recommendations were not implemented, as confirmed by the surveyor's observations. The surveyor noted visible gaps in the front door, missing tiles in a resident's bathroom, and broken flooring in the employee break room, all of which were previously documented by the pest control company. Interviews with the Maintenance Director and the Pest Control Employee revealed a disconnect between the documentation of pest control measures and the actual implementation of necessary repairs. The Maintenance Director claimed that repairs had been made, but the pest control documentation and surveyor's observations indicated otherwise. This failure to address structural issues contributed to the ongoing pest problem, compromising the facility's pest control efforts.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach, which is a violation of the facility's policy. Resident #82, who was admitted with diagnoses including stroke and hemiplegia, was found to have their call light tied up against the wall and out of reach on multiple occasions. Despite being cognitively intact, as indicated by a BIMS score of 14 out of 15, Resident #82 reported difficulty reaching the call light, which was confirmed through observations and interviews with staff. Similarly, Resident #120, who was admitted with dementia and diabetes, also had their call light out of reach. This resident, who also had a BIMS score of 14, requires partial to moderate assistance with daily tasks. Observations showed the call light hanging down from the wall and behind the light structure, making it inaccessible. Interviews with a CNA and the Assistant Director of Nursing confirmed that call lights should always be within reach of residents, highlighting the facility's failure to adhere to its own policy.
Invalid Advance Directives Documentation
Penalty
Summary
The facility failed to ensure that the Advance Directives for a resident were valid and properly documented in the medical record. The resident, who was admitted in April 2019, had severe cognitive impairments and diagnoses including cerebral infarction, dysphagia, bipolar disorder, and paranoid schizophrenia. The resident's physician order indicated a DNR/DNI status, and a MOLST form dated September 2022 showed that consent was obtained over the phone. However, the MOLST form lacked a necessary signature from either the resident or the Health Care Proxy, rendering it invalid. Interviews with facility staff, including a social worker and two nurses, confirmed that a MOLST form is not valid without a signature from the resident or their Health Care Proxy. The staff acknowledged that verbal phone consent is not acceptable, and the MOLST should have been signed and returned by mail or email. This oversight in obtaining a valid signature for the MOLST form led to the deficiency in ensuring the resident's advance directives were properly executed and documented.
Inaccurate MDS Assessment for Discharged Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a discharged resident. The resident, who had diagnoses including cervical disc disorder, chronic pain, and monoplegia of the upper limb following a cerebral infarction, was admitted in August 2024. The MDS assessment dated August 26, 2024, indicated the resident had intact cognition and required supervision for ambulation. However, the discharge MDS assessment dated November 22, 2024, was inaccurately coded as a planned discharge to a short-term general hospital, while the resident was actually discharged home. This discrepancy was confirmed during an interview with the MDS Nurse, who acknowledged the inaccuracy in the coding of the discharge MDS assessment.
Failure to Submit PASARR Level I for Resident with SMI
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I was requested for a resident who was screened to have a Serious Mental Illness (SMI) and exceeded the discharge exception of 30 calendar days. The resident, admitted in September 2019, had a diagnosis of bipolar disorder and was initially expected to stay in the facility for less than 30 days, as certified by the hospital's attending or discharge practitioner. However, the resident continued to stay beyond the 30-day exemption period. The facility did not submit the required Level I PASARR to the Department of Mental Health (DMH) or its designee by the 28th calendar day from admission, as required when a resident's stay exceeds the initial exemption period. The medical record lacked documentation of a PASARR Level I submission after the resident's stay extended beyond 30 days. During interviews, the social worker acknowledged the oversight and noted that the PASARR request and determination should have been documented in the resident's medical record.
Failure to Implement Physician Orders and Obtain Necessary Authorizations
Penalty
Summary
The facility failed to implement physician orders for several residents, leading to deficiencies in care. For Resident #59, the facility did not obtain monthly weights as ordered by the physician. Despite the order being present in the resident's records, the weight log showed no entries since the order was written, and the order was not included on the nurses' documentation forms. This oversight was confirmed by a nurse during an interview. Resident #11 had a small skin tear on the left shin, which was covered with a dressing by a nurse. However, there was no physician's order for the dressing, and the dressing was not dated. The nurse acknowledged that a skin incident report should have been completed, and a treatment order should have been obtained from a doctor or nurse practitioner. The Assistant Director of Nursing confirmed that the proper protocol was not followed in this case. For Resident #132, the facility did not have a physician's order for a Registered Nurse to pronounce the resident's death. The resident was found unresponsive, and CPR was initiated. EMTs took over and contacted a doctor to pronounce the death, but the nurse did not have the necessary order to do so. Additionally, Residents #131 and #133 were discharged from the facility without a physician's order, which is required for discharge. The Assistant Director of Nursing and the Regional Administrator confirmed that the necessary orders were not obtained for these discharges.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide necessary supervision during meals for a resident with severe cognitive impairment and other medical conditions. The resident, who was admitted with diagnoses including lack of coordination, altered mental status, dysphagia, and contracture of the left hand, was observed eating meals without supervision on multiple occasions. The facility's policy on Activities of Daily Living, which includes dining, requires supervision for residents who need assistance. The resident's care plan specifically indicated the need for continuous supervision while eating due to risks associated with dysphagia and poor coordination. Observations by the surveyor revealed that the resident was left unsupervised during meals, resulting in food spillage and wet coughs, which could indicate difficulty swallowing. Interviews with facility staff, including a CNA and a nurse, confirmed that the resident should have been supervised at all times during meals to prevent aspiration and provide assistance as needed. Despite these requirements, the resident was left alone during meal times, highlighting a failure to adhere to the care plan and facility policy, thereby compromising the resident's safety and well-being.
Failure to Identify and Document Skin Conditions
Penalty
Summary
The facility failed to provide quality care for a resident by not identifying and appropriately documenting skin conditions on the resident's shins. The resident, who has a history of nontraumatic subdural hemorrhage, lack of coordination, adult failure to thrive, and bipolar disorder, was observed with a small round dark red area on the left shin and several scattered bluish areas on the right shin. These observations were made during multiple visits, yet the facility's records did not reflect these findings. Specifically, a weekly skin check conducted prior to these observations incorrectly indicated that there were no open areas or marks on the resident's skin. Additionally, there was no physician's order for a dressing on the resident's left shin, despite the presence of a small dressing observed during visits. Nurse #3, who conducted the skin check, admitted to not noting the skin areas on the resident's shins and acknowledged that a skin incident report should have been completed. The lack of documentation and failure to follow proper procedures for skin assessments and treatment orders contributed to the deficiency in care for the resident.
Failure to Provide Resident with Hearing Aids
Penalty
Summary
The facility failed to provide a resident with necessary hearing devices, resulting in a deficiency. The resident, admitted in October 2022, has a diagnosis of sensorineural hearing loss and moderate cognitive impairment. The resident's Minimum Data Set (MDS) assessment indicated moderate difficulty hearing, and physician orders specified that the resident should wear hearing aids daily. However, during the survey, the resident was not observed wearing hearing aids, and staff interviews revealed that the hearing aids were missing. Certified Nursing Assistant (CNA) #7 stated that the resident did not have hearing aids, while Nurse #4 acknowledged the resident had hearing aids but was not wearing them due to dead batteries. The nurse was unable to locate the hearing aids in the medication cart, where they were supposed to be stored. The Assistant Director of Nursing (ADON) confirmed the hearing aids were missing and should have been documented and replaced if lost. Despite efforts to locate the hearing aids, they remained missing, indicating a failure in the facility's responsibility to ensure the resident's access to necessary hearing devices.
Failure to Ensure Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident at risk for developing pressure ulcers received necessary treatment and services to prevent new ulcers from developing. Specifically, the facility did not ensure that the resident was wearing Prevalon boots to offload heels while in bed, as ordered by the physician. The resident, who was admitted with a diagnosis of a pressure ulcer on the left heel and had severe cognitive impairment, was observed multiple times with heels directly on the mattress and the Prevalon boots unworn beside the bed. The resident's care plan and physician's orders clearly indicated the need for the resident to wear Prevalon boots while in bed for pressure relief and skin protection. However, there was no documentation in the medical record of the resident refusing or removing the boots. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the resident should have been wearing the boots as per the physician's orders, and any refusal or removal should have been documented, which was not done.
Failure to Provide Proper Foot Care for a Resident
Penalty
Summary
The facility failed to provide proper foot care for a resident with multiple health conditions, including end-stage renal disease, type 2 diabetes, aphasia, and cerebral infarction. The resident was admitted in December 2024 and was dependent on staff for hygiene, bathing, and dressing due to moderate cognitive impairments. Despite a physician's order for daily diabetic foot care and documentation of adverse findings, the resident's toenails were observed to be long, thick, and curling around the toes on multiple occasions in February 2025. The facility's policy required toenails to be trimmed by qualified personnel, and documentation should have included assessments of the feet, including hygiene and the condition of the toenails. The facility's records, including the Treatment Administration Record and nursing progress notes, failed to document the condition of the resident's toenails or notify the medical doctor of the overgrown nails. Additionally, the weekly skin checks since admission did not indicate the condition of the toenails. A dialysis communication form dated February 6, 2025, noted the need for podiatry services due to overgrown toenails. During an observation with the Regional Administrator and Staff Development Coordinator, it was acknowledged that nursing should have documented the condition of the nails and informed the doctor, indicating a lapse in following the facility's policy and physician's orders.
Failure to Implement Hand Carrot Orthotic for Resident
Penalty
Summary
The facility failed to implement the use of a hand carrot orthotic for a resident with a left hand contracture, as per the physician's order and rehabilitation plan of care. The resident, who was admitted in February 2023, has severe cognitive impairment and functional limitations in the range of motion of the upper extremity. Observations by the surveyor on multiple occasions revealed that the resident was not using the hand carrot, and it was not present in the resident's room. The resident reported pain in the left hand during these observations. The physician's order and care plan required the resident to wear the hand carrot to prevent contracture, with nursing staff responsible for its application and daily skin inspections. Despite these directives, there was no documentation indicating the resident's refusal to wear the orthotic. Interviews with the Director of Rehabilitation, a nurse, and the Assistant Director of Nursing confirmed that the resident should have been using the hand carrot, and any refusal should have been documented. The lack of adherence to the prescribed care plan and absence of documentation of refusal led to the deficiency identified by the surveyor.
Failure to Investigate Falls and Incidents
Penalty
Summary
The facility failed to investigate falls for two residents, leading to deficiencies in accident hazard prevention and supervision. Resident #13, who has multiple sclerosis and other conditions, fell in the outdoor smoking area. Despite being informed by a staff member and the resident himself, Nurse #5 did not initiate a post-fall investigation because the resident denied the fall. The Director of Rehab and the Regional Administrator confirmed that a post-fall investigation should have been conducted immediately, but it was not initiated. Resident #133, who has a cervical disc disorder and other conditions, got his hand caught in an elevator door. Although an x-ray was ordered and the care plan was updated, there was no incident report or investigation initiated for this incident. The Assistant Director of Nursing and the Staff Development Nurse acknowledged the lack of an incident report and investigation, which should have included an assessment of the elevator's operation and functioning.
Deficiencies in Respiratory Care Services
Penalty
Summary
The facility failed to provide appropriate respiratory care services for three residents, leading to deficiencies in their care. Resident #30, who has chronic obstructive pulmonary disorder and diabetes, was observed with a nebulizer mask that was not bagged and tubing that was undated, contrary to facility policy. The nebulizer equipment was found in unsanitary conditions, with the mask in direct contact with surfaces and tubing lying on the floor. The facility's policy requires nebulizer masks to be bagged and tubing to be dated and changed weekly, but these procedures were not followed. Resident #68, diagnosed with respiratory failure, asthma, and coronary artery disease, was found to have an oxygen flow rate set higher than the physician's order of 2-6 liters. Observations showed the oxygen concentrator set at 10 liters and later at 8.5 liters. Staff were aware that the resident self-adjusted the oxygen flow rate but did not monitor it effectively, and the care plan was not updated to address this behavior. Resident #74, with chronic obstructive pulmonary disease and congestive heart failure, was receiving supplemental oxygen at 5 liters instead of the prescribed 4 liters. Additionally, the resident's BiPAP mask was found to be dirty with crusted residue, indicating it had not been cleaned as per the physician's order. The facility's failure to adhere to the prescribed oxygen settings and maintain the cleanliness of respiratory equipment contributed to the deficiencies in care for these residents.
Failure to Provide Behavioral Health Care for Residents
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents, leading to deficiencies in their care. Resident #85, who has a secondary diagnosis of Substance Use Disorder (SUD), did not have an individualized care plan developed to address their specific needs related to their SUD history. Despite having a history of opioid dependence and being due for injectable buprenorphine, the resident was unaware of any support services available at the facility. The social service assessment inaccurately recorded the resident's history of opioid use, and the medical record lacked a person-centered care plan to mitigate potential triggers for relapse. Resident #16, diagnosed with dementia and exhibiting severe cognitive impairment, did not receive the recommended behavioral health interventions. The Psychiatric Nurse Practitioner recommended starting Ativan PRN for anxiety and agitation, but this recommendation was not communicated to the physician or implemented. The resident continued to exhibit disruptive behaviors, and the facility's documentation did not reflect any active or completed orders for the recommended medication. The Assistant Director of Nursing acknowledged that the facility should have followed the NP's recommendation, but the Director of Nursing was unavailable for comment. These deficiencies highlight the facility's failure to ensure that residents with behavioral health needs receive appropriate and timely interventions. The lack of individualized care plans and failure to implement recommended treatments contributed to the residents not attaining or maintaining their highest practicable mental and psychosocial well-being.
Pharmacy Fails to Identify Medication Irregularity
Penalty
Summary
The facility failed to ensure that the pharmacy identified medication irregularities for a resident, leading to a deficiency. Specifically, an antidepressant medication, Sertraline, was incorrectly prescribed for the treatment of chronic obstructive pulmonary disease (COPD) and associated symptoms of nausea and vomiting. The pharmacy reviewed the order but did not identify the incorrect use of the medication, which was intended for the resident's diagnosis of depression. The resident involved had multiple diagnoses, including COPD, depression, cerebral vascular accident, and Parkinson's disease, and was severely cognitively impaired. Interviews with facility staff, including a nurse and the Regional Administrator, confirmed that the Sertraline was prescribed for depression, not for COPD or nausea and vomiting. The pharmacy was expected to identify such errors during their monthly medication reviews but failed to do so, resulting in the deficiency.
Failure to Reassess PRN Ativan Order
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the administration of Ativan, a benzodiazepine used for anxiety. The resident, who was admitted in April 2019, had diagnoses including cerebral infarction, dysphagia, bipolar disorder, and paranoid schizophrenia, and was assessed to have severe cognitive impairments. A physician's order dated January 28, 2025, prescribed Ativan 0.5 mg to be given every four hours as needed for anxiety agitation. However, the facility did not include a stop and re-assessment date for this PRN medication order, as confirmed by interviews with Nurse #2 and the Staff Development Coordinator on February 13, 2025.
Inaccurate Documentation of Hearing Aids and Splint Use
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. For one resident with sensorineural hearing loss, the facility did not accurately document the use of hearing aids. Despite physician orders indicating that the resident should wear hearing aids daily, observations during the survey revealed that the resident was not wearing them, and the hearing aids were reportedly lost. The Medication Administration Record inaccurately reflected that the hearing aids were applied, and staff interviews confirmed the discrepancy, with the Assistant Director of Nursing acknowledging the issue. Another resident, who had severe cognitive impairment and a contracture of the left hand, was not wearing a prescribed hand carrot splint, despite documentation indicating otherwise. Observations showed the resident without the splint on multiple occasions, and staff interviews confirmed that the splint was not being used as required. The Treatment Administration Record inaccurately documented that the resident was wearing the splint, and the Director of Rehabilitation and nursing staff acknowledged the failure to ensure the resident's compliance with the splinting program. These deficiencies highlight a failure in the facility's documentation practices and adherence to physician orders, resulting in inaccurate medical records for the residents involved. The staff's failure to accurately document and implement care plans as prescribed contributed to the deficiencies observed during the survey.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which is essential for residents and visitors to view. During the survey, the surveyor could not locate the staffing posting. An observation and interview on February 12, 2025, revealed that the Appointment Coordinator found an empty plastic frame by the receptionist, which was intended for the daily staff posting. The Appointment Coordinator mentioned that when she was the scheduler, she posted the staffing daily, and the current scheduler should be doing the same. However, during an interview, the current Scheduler admitted that she did not post the staffing information for that day or the previous day and had not done so since she started working at the facility a few months ago.
Failure to Maintain Accurate Health Care Proxy Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by their policies and professional standards. For both residents, Health Care Proxy (HCP) activation forms were filled out and signed by a physician, indicating that the residents were deemed incompetent to make their own health care decisions. However, the facility did not have the corresponding HCP forms or designated Health Care Agents (HCA) on file in the medical records. This oversight was discovered during a review of the residents' medical records, which showed no documentation supporting the existence of an HCP or designated HCA. The deficiency was further highlighted during interviews with facility staff. The Medical Director expected that the nursing staff would ensure the presence of a HCP form with a designated HCA on file and that the HCA would be notified upon activation of the HCP. However, the Medical Director was not informed that the necessary documentation was missing for the two residents. The Director of Nurses admitted to filling out the activation forms without reviewing the residents' records for HCP and HCA designations, acknowledging that this step should have been taken.
Failure to Serve Menu as Planned
Penalty
Summary
The facility failed to serve the menu as planned for a breakfast meal. On the specified date, the cook was observed serving mixed fruit and a muffin, while the menu indicated that a 4oz yogurt should have also been served. The cook admitted to running out of yogurt and did not make a substitution. The Food Service Director was unaware of the shortage and stated that he would have expected the staff to inform him so that an approved substitution could be made by the dietitian.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform two residents of their right to be informed about the use of psychotropic medications. Resident #19, who was admitted with diagnoses including dementia and unspecified psychosis, was found to be taking Seroquel and Trazodone without documented consent. Despite the facility's policy requiring informed written consent for psychotropic medications, no such consent was found in Resident #19's medical records. Interviews with staff revealed that the resident's family had not signed the consents, and there was no established process to handle unresponsive healthcare proxies. The Assistant Director of Nursing acknowledged that the doctor should be informed if a psychotropic consent is not signed, but this was not documented in the resident's records. Similarly, Resident #49, admitted with diagnoses including Alzheimer's Disease and psychotic disturbance, was also found to be taking Seroquel without documented consent. The resident's medical records did not contain the required psychotropic consent forms, despite the facility's policy. Interviews with nursing staff and the Corporate Nurse confirmed that consents should be obtained on admission, with new orders, and annually, but no consent was found for Resident #49. This indicates a systemic issue in the facility's process for obtaining and documenting informed consent for psychotropic medications.
Failure to Follow Physician Orders for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents, leading to deficiencies in care. Resident #53, who was admitted with diagnoses including quadriplegia and pressure-induced deep tissue damage of the left heel, had physician orders to offload bilateral heels every shift. However, observations on multiple occasions revealed that the resident's heels were directly placed on the mattress, contrary to the physician's orders. The care plan did not indicate any refusal from the resident to have their heels floated, and a nurse confirmed that the heels should be offloaded at all times while in bed as per the orders. Similarly, Resident #97, who was admitted with severe cognitive impairment and at high risk for developing pressure ulcers, had physician orders to wear Prevalon boots on both feet every shift. Observations showed that the resident was not wearing the Prevalon boots on multiple occasions. The care plan did not indicate any refusal from the resident to wear the boots, and a CNA and a nurse both confirmed that the resident should have been wearing the boots according to the physician's orders. The Director of Nursing also acknowledged that physician orders should be followed as ordered.
Failure to Provide Meaningful and Person-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of meaningful and person-centered group activities designed to meet the interests and support the physical, mental, and psychosocial well-being of residents on two out of three resident care units. During a Resident Group meeting, all eight residents reported that there had been no group activities for months, despite the activity calendar indicating otherwise. Scheduled activities such as gentle exercise and Bible study did not take place, and residents were observed not being engaged in any meaningful activities. The Social Worker and a Volunteer were present but did not effectively engage the residents in the scheduled activities. The facility's activity calendar indicated scheduled activities, but these were not carried out. Observations revealed that residents were left unengaged, with some slumped in their wheelchairs or not interacting with the materials provided. The facility has been without an activities director since December, and the position remains unfilled. Volunteers and other staff have been attempting to fill in, but their efforts have not been sufficient to meet the residents' needs for meaningful engagement. The Corporate Nurse confirmed the lack of an activities director and the reliance on volunteers and other staff to provide minimal activities.
Failure to Maintain Emergency Supplies for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. Specifically, the facility did not maintain visible and accessible emergency equipment supplies at the bedside for a resident with End Stage Renal Disease (ESRD). The facility's policy indicated that residents with ESRD should be cared for according to recognized standards, and staff should be trained to recognize and intervene in medical emergencies such as hemorrhages. However, during observations, it was found that the emergency supplies were not present at the resident's bedside or in the room. The resident, who was admitted in September 2018 and had diagnoses including ESRD and Chronic Kidney Disease stage 5, was observed without the necessary emergency supplies on multiple occasions. The resident's dialysis care plan specifically required emergency supplies to be kept at the bedside. Both the resident and a nurse confirmed the absence of these supplies, which are crucial in the event of bleeding from the fistula site. The facility's Corporate Nurse also acknowledged that an emergency supply kit should have been present at the bedside for residents requiring dialysis treatment.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure it was free from a medication error rate of greater than 5 percent. During a medication pass, a nurse made five errors in 28 opportunities, resulting in a medication error rate of 17.86%. These errors impacted two residents. For Resident #99, the nurse prepared and was about to administer several medications that were scheduled for bedtime instead of the morning. Additionally, the nurse omitted the administration of polyethylene glycol, which was scheduled for 9:00 A.M., citing the resident's preference, although the order did not reflect this preference. The nurse admitted that she would have administered the wrong medications at the wrong time if not stopped by the surveyor and acknowledged the omission of the polyethylene glycol dose. For Resident #8, the nurse administered metoprolol tartrate without checking the resident's blood pressure, despite the medication packaging indicating that the medication should be held if the systolic blood pressure was less than 100 or the heart rate was less than 60. The nurse admitted that she should have checked the blood pressure before administering the medication and noted that the blood pressure parameters were not correctly scheduled in the physician's order. The Director of Nursing confirmed that nurses are expected to follow the five rights of medication administration and that medications should be given as ordered, with any resident preferences reflected in the orders. He also stated that parameters for medications requiring them should be checked.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to the manufacturer's guidelines on one of three sampled medication carts. Specifically, the surveyor observed that several medications, including timolol eye drops, insulin glargine pens, latanoprost eye drops, and liquid protein, were opened and undated. This observation was made on the Gardner 2 High side medication cart. The facility's policy requires that medications be dated when opened to ensure their purity and potency, but this was not followed in the observed instances. During interviews, both Nurse #1 and the Director of Nursing confirmed that eye drops, insulins, and liquid protein should be dated when opened. The facility's policy also mandates that outdated, contaminated, or deteriorated medications be immediately removed from inventory and disposed of according to procedures. However, the failure to date these medications indicates non-compliance with both the facility's policy and State and Federal laws regarding the storage and labeling of drugs and biologicals.
Failure to Follow Therapeutic Diet Orders
Penalty
Summary
The facility failed to follow a therapeutic diet as prescribed by the attending physician for one resident out of a total sample of 26 residents. Specifically, the facility did not ensure that the kitchen provided a fluid restriction as ordered by the physician for Resident #15. The resident, who was admitted with diagnoses including hyponatremia, orthostatic hypotension, and polydipsia, had a physician's order for a 1-liter fluid restriction. However, observations revealed that the resident was consistently provided with more fluids than prescribed during meals, and the diet slips did not indicate the fluid restriction. Interviews with staff, including a CNA, a nurse, and the Food Service Director, indicated a lack of awareness and communication regarding the resident's fluid restriction. The facility's policies on fluid restrictions and therapeutic diet orders were not followed. The policy required nursing personnel to inform the dietary department of fluid restrictions and to specify the cc levels permitted. However, the surveyor observed that the resident's diet slips did not include the fluid restriction, and the resident was provided with excessive fluids during meals. The Food Service Director confirmed that he was not aware of any fluid restrictions in the facility and that the kitchen slip for Resident #15 did not indicate the fluid restriction. The Director of Nursing also acknowledged that the kitchen should be aware of the therapeutic diet and provide the fluid restriction on the tray ticket.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurately documented for two residents. For Resident #40, who was admitted with diagnoses including dementia and osteoarthritis, the facility did not document wound treatments as complete. The resident had a stage 4 pressure ulcer and required daily dressing changes as per the physician's order. However, the Treatment Administration Record (TAR) showed missing documentation for several days in March 2024. Observations confirmed that the dressings were changed, but the documentation was not completed. Both a nurse and the Director of Nursing acknowledged the failure to document the treatments properly. For Resident #97, who had severe cognitive impairment and was at high risk for developing pressure ulcers, the facility failed to accurately document the application of Prevalon boots. The physician's order required the boots to be worn every shift with skin checks. Despite the TAR indicating that the boots were applied, multiple observations over several days showed that the resident was not wearing the boots. Interviews with a CNA and a nurse revealed a lack of awareness and improper documentation practices. The Director of Nursing confirmed that the resident often refused the boots, but the documentation inaccurately reflected their application.
Failure to Prevent Bed Entrapment
Penalty
Summary
The facility failed to ensure a gap in the bed was filled to prevent possible entrapment for one resident out of a total sample of 26 residents. The facility's policy on Side Rail Entrapment Risk indicated that the space between the bed rail and the mattress and the headboard and the mattress should be filled to prevent an individual from falling between the mattress and bed rails. However, observations on multiple occasions revealed a large gap between the mattress and the footboard of the resident's bed, with a foam bolster intended to fill the gap observed on top of the bedside dresser instead of in its proper place. The resident in question was admitted to the facility with diagnoses including cerebral vascular disease, anoxic brain damage, and muscle weakness, and was totally dependent on staff for all activities of daily living. Interviews with facility staff, including a CNA and a nurse, confirmed that the foam bolster should have been placed between the mattress and the footboard to prevent entrapment. The Director of Nursing also acknowledged that the gap should have been filled by the bolster as the bed was assessed for potential entrapment.
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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