Day Brook Village Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Holyoke, Massachusetts.
- Location
- 298 Jarvis Avenue, Holyoke, Massachusetts 01040
- CMS Provider Number
- 225269
- Inspections on file
- 21
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Day Brook Village Senior Living during CMS and state inspections, most recent first.
The facility did not ensure timely destruction of discontinued controlled substances, instead storing them in the Administrator's office for over a year. Required dual nurse verification for transferring controlled substances in medication log books was not consistently performed, and multiple types of controlled medications for several residents remained unsecured for extended periods.
Staff did not follow residents' documented meal and beverage preferences as indicated on meal tickets, instead relying on personal knowledge of preferences and providing only limited beverage options. As a result, residents did not receive specific foods and fluids ordered for their clinical needs, despite these items being available and documented by the RD and FSD.
Surveyors found that the facility did not follow safe food handling practices, with multiple unlabeled and undated food and beverage items observed in the kitchen's refrigerator, freezer, and dry storage. Staff interviews confirmed that proper labeling and dating procedures were not followed, especially among new dietary staff, in violation of facility policy.
The facility did not maintain an effective pest control program, leading to a persistent fruit fly infestation in a resident unit's pantry, hallways, and two residents' rooms. Despite repeated pest control company recommendations to repair a large hole under the pantry sink, the issue remained unresolved, and unsanitary conditions such as food residue and rodent droppings were also observed. Staff and visitors reported frequent sightings of fruit flies, but communication and corrective action were lacking.
Staff did not consistently place the call light within reach for a resident with left-sided hemiplegia and Parkinson's Disease, despite care plan and policy requirements. Observations and staff interviews confirmed that the call light was left out of reach on multiple occasions, preventing the resident from calling for assistance when needed.
A resident with severe cognitive impairment and multiple diagnoses was admitted without a complete nursing admission assessment or proper documentation of cognitive and mood status. The MDS assessment was inaccurately completed by a social worker who had not seen the resident. The resident subsequently eloped from the facility, with staff only discovering the absence after the fact.
A resident with moderate cognitive impairment and a need for assistance with personal hygiene was not provided with necessary grooming support, specifically facial hair removal, despite facility policy and a care plan indicating this need. Staff interviews confirmed the resident's preference and the expectation to offer grooming assistance, but observations showed the resident remained with unwanted facial hair, and this aspect of care was not documented or addressed.
A resident with severe cognitive impairment and on Hospice care did not receive timely comfort medications due to the facility's failure to implement multiple documented Hospice recommendations. Despite repeated urgent requests and physician approval, the necessary medications were not ordered for 55 days, contrary to facility policy and professional standards.
A resident with a history of substance use disorder, Wernicke Encephalopathy, anxiety, and depression was not assessed for wandering or elopement risk upon admission, and no individualized interventions were implemented. The resident left the facility without staff awareness, and the required elopement prevention protocols were not followed.
Two residents at risk for nutritional decline did not receive appropriate nutritional care: one experienced significant weight loss without timely intervention from the dietician, and another with diabetes was given unapproved nutritional supplements with higher carbohydrate content than ordered, leading to inaccurate documentation and potential mismanagement of blood sugar. Staff provided supplements based on preference rather than physician orders, and there was a lack of oversight and communication among staff regarding proper supplement administration.
A resident with ESRD on hemodialysis was not accurately monitored for fluid intake, as the facility set the daily fluid allotment at 1800 ml instead of the physician-ordered 1200 ml, and failed to consistently total daily intake. Staff interviews and record reviews confirmed that the electronic medical record system contained incorrect preset values and that required documentation and monitoring were not performed as per facility policy.
The facility did not ensure that all required QAPI Committee members, including the Infection Preventionist (IP), attended each quarterly meeting. For one meeting, the IP was absent because the facility did not have an IP at that time, as confirmed by the Administrator.
Staff did not follow Enhanced Barrier Precautions during wound care for a resident with a pressure ulcer, failing to wear required gowns despite clear policy and signage. Additionally, a medication administration cart was found unclean, with dried spills, pill particles, and rusted scissors, and the DON was unable to confirm when it was last cleaned.
Two residents who were eligible and had consented to receive Pneumococcal vaccinations did not receive them as required by facility policy and CDC guidelines. Both individuals had medical conditions and no contraindications, yet their clinical records showed no evidence of vaccine administration, a lapse confirmed by the Regional Infection Preventionist.
A resident who was not their own responsible party did not receive the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) through their Health Care Proxy after their Medicare Part A skilled services coverage ended. The Clinical Reimbursement Coordinator confirmed the notice was not issued, and the resident remained in the facility without discharge.
A resident with cardiac-related diagnoses was prescribed an antiplatelet medication, but staff did not accurately code this medication on the MDS assessment. The MDS nurse confirmed the omission and stated that the assessment should have included the antiplatelet medication, as required by the RAI Manual.
A resident with dementia and depressive disorder developed influenza symptoms and was tested for a respiratory panel. Although the test returned positive for influenza the next day, nursing staff did not obtain or communicate the results to the provider for six days. This delay prevented timely initiation of antiviral treatment, as staff failed to check the lab printer or follow up with the lab, and the NP and infection preventionist were not informed until it was too late for effective intervention.
A resident exhibiting fever and respiratory symptoms was tested for Influenza, with a positive result reported by the lab the next day. Nursing staff did not notify the ordering provider of the result until six days later, as they failed to follow up on the laboratory report and did not check or act on the lab printer output, leaving the provider and staff unaware of the resident's positive status.
Three residents who tested positive for Influenza did not have physician's orders or documentation for Droplet Precautions, and one resident's CNA ADL Flow Sheets were incomplete over multiple shifts, despite requiring staff assistance. Staff interviews revealed confusion about responsibility for obtaining necessary orders and completing documentation.
Failure to Properly Document and Destroy Controlled Substances
Penalty
Summary
The facility failed to maintain proper records and procedures for the receipt, disposition, and destruction of controlled substances on one unit. Controlled medications, including opioids, narcotics, and sedatives, were removed from two locked medication carts and stored in the Administrator's office for over a year without being destroyed as required by facility policy. Documentation showed that these medications were removed from the medication carts on multiple occasions, but there was no evidence that destruction had occurred, despite being documented for disposal. Additionally, the controlled substance medication log books revealed that transfers of controlled substances from one page to another were not consistently verified and documented by two licensed nurses, as required by policy. Observations confirmed that multiple controlled substances for several residents, such as Tramadol, Lorazepam, Oxycodone, Morphine Sulfate, Hydromorphone, Lyrica, Clonazepam, Ambien, Dilaudid, Vimpat, and Nayzilam, were stored under lock and key in the Administrator's office. Interviews with nursing staff and the DON confirmed that the required dual verification for medication transfers and timely destruction of discontinued controlled substances did not occur. The facility's failure to follow its own policies and regulatory requirements for controlled substance management was directly observed and acknowledged by staff.
Failure to Honor Resident Meal and Beverage Preferences
Penalty
Summary
The facility failed to honor residents' meal and beverage preferences as indicated on their meal tickets, despite these tickets being based on resident needs and preferences and reviewed by the Registered Dietitian (RD). During multiple meal observations, staff were seen distributing meals and beverages that did not match the choices listed on the residents' meal tickets. For example, residents were only offered orange juice or cranberry juice, regardless of their documented preferences, and one resident received orange juice despite their ticket specifying only Lactaid milk. Additionally, specific food items such as fortified cream of wheat, fruited yogurt, and fresh melon fruit cup, which were indicated on meal tickets, were not provided to residents, even though these items were available in the facility. Interviews with Certified Nurses Aides (CNAs), nursing staff, and dietary staff revealed that staff relied on their personal knowledge of residents' likes and dislikes rather than following the documented meal tickets. CNAs and other staff members stated that they did not follow the meal tickets, believing their familiarity with residents' preferences was sufficient. The RD and Food Service Director (FSD) confirmed that the meal tickets should have been followed and that the failure to do so resulted in residents not receiving their chosen or clinically indicated meals and beverages. The deficiency was further evidenced by the RD's review of specific cases where residents did not receive the prescribed fortified foods necessary for their clinical conditions, such as weight loss. The FSD acknowledged that meal tickets were not reviewed or honored as required, and staff substituted items based on their own judgment rather than the documented preferences and dietary needs. The facility's policy required that residents' nutritional needs and preferences be met, but this was not consistently implemented on the observed unit.
Failure to Label, Date, and Properly Store Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to safe food practices in the main kitchen, specifically regarding the labeling, dating, and storage of food and beverage items intended for resident consumption. During an initial walk-through of the main kitchen, the surveyor observed multiple unlabeled and undated food items in the walk-in refrigerator, walk-in freezer, and dry storage area. These included large pitchers of juice, boxes and bags of various frozen foods such as donuts, waffles, onion rings, French fries, cookie dough, spring rolls, lemon bars, as well as dry goods like spaghetti, pudding mix, muffin mix, lasagna, and oatmeal. Some items were also found open to air, further increasing the risk of contamination. Interviews with dietary staff and the Food Service Director confirmed that the observed food items should have been labeled and dated after opening, in accordance with facility policy. Staff acknowledged that many employees in the main kitchen were new and that proper procedures for labeling and dating were not followed. The facility's policy requires all foods stored in refrigerators, freezers, and dry storage to be covered, labeled, and dated to ensure safety and prevent foodborne illness, but these practices were not consistently implemented.
Failure to Maintain Effective Pest Control Program Resulting in Fruit Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program on one of its resident units, specifically Unit Two, resulting in the presence of fruit flies in multiple areas including the pantry, hallways, and two residents' rooms. Observations by surveyors and reports from staff and visitors confirmed ongoing sightings of fruit flies in these locations, particularly during meal times. The facility's own pest control policy required ongoing efforts to keep the building free of insects and rodents, but these measures were not effectively implemented. Review of pest control service inspection reports revealed that a large hole in the wall around pipes under the Unit Two Pantry sink had been repeatedly identified as a potential entry point for pests since at least 2019. Despite ongoing pest control visits and repeated recommendations from the contracted pest control company to repair the hole, the issue remained unaddressed. The hole was observed by both the surveyor and the Maintenance Director, who initially denied its existence and later downplayed its significance, even though pest control reports consistently highlighted it as a concern. Interviews with staff indicated that sightings of fruit flies were common, but not always communicated to facility leadership. The Maintenance Director acknowledged the ongoing issue and confirmed that pest control recommendations were his responsibility, yet the necessary repairs had not been completed. The Administrator was under the impression that the fruit fly problem was recent, despite evidence to the contrary. Additionally, unsanitary conditions such as food residue and rodent droppings were observed in the pantry, further contributing to the pest issue.
Failure to Ensure Call Light Accessibility for Resident with Hemiplegia
Penalty
Summary
Facility staff failed to provide appropriate access to the call light for a resident with left-sided hemiplegia and Parkinson's Disease, who was also receiving hospice care. The resident's care plan specifically required that the call light be placed within reach on the unaffected side, and facility policies mandated that call lights be accessible to residents at all times. Despite these requirements, observations revealed that the call light was repeatedly left out of the resident's reach—once on top of the nightstand on the left side of the bed and another time clipped to the left side of the bed below the lowest bar of the siderail, both inaccessible to the resident. Interviews with staff confirmed that the call light had been moved during care activities and not returned to an accessible position. The resident reported being unable to find the call light when needing to request medication. Staff acknowledged the importance of keeping the call light within reach and admitted to forgetting to reposition it after providing care. The Director of Nursing also confirmed that call lights should always be within reach to allow residents to alert staff as needed.
Failure to Complete Admission Assessment Resulting in Resident Elopement
Penalty
Summary
The facility failed to conduct a complete and timely admission assessment for a resident with diagnoses including alcohol withdrawal, Wernicke Encephalopathy, anxiety, and depression. Upon admission, there was no nursing admission assessment, no nursing admission note documenting the resident's arrival, cognitive patterns, mood and behavior, psychological well-being, or discharge planning. The required direct observation and communication to complete an accurate assessment were not performed. As a result, the resident eloped from the facility shortly after admission. Record review showed that the Minimum Data Set (MDS) assessment was inaccurately completed, with a BIMS score of 0 documented by a social worker who had not seen or assessed the resident. Interviews confirmed that the social worker did not assess the resident and that the MDS assessment was not based on direct observation. Nursing staff reported that the resident expressed a desire to leave, and later, the resident was found to have left the facility without proper documentation or understanding of the discharge process.
Failure to Provide Grooming Assistance for Resident Requiring ADL Support
Penalty
Summary
The facility failed to provide necessary grooming assistance to a resident who required help with personal hygiene, specifically facial hair removal. According to the facility's Activities of Daily Living (ADLs) policy, residents are to receive care and services for hygiene, including grooming, based on their assessed abilities and care plan. The resident in question was moderately cognitively impaired, required assistance with personal hygiene, and had a care plan indicating a need for help with grooming. Despite this, the resident was observed on two consecutive days with long, thick facial hair on the chin, which the resident stated was undesirable and that staff would help remove it only when reminded. Interviews with staff revealed that the resident needed assistance with all ADLs and had previously expressed a preference for not having facial hair. The CNA familiar with the resident acknowledged that if the resident did not request facial hair removal, she would offer to assist, but also stated that documentation of this care was not required. The DON confirmed that CNAs are expected to ask residents with facial hair if they would like it removed and that this aspect of daily ADL care was not addressed for the resident. The deficiency was identified through observation, interview, and record review, showing a failure to provide grooming assistance as required by the resident's care plan.
Delay in Implementation of Hospice Comfort Medication Orders
Penalty
Summary
The facility failed to provide timely treatment and services in accordance with professional standards of practice for a resident receiving Hospice care. Despite multiple documented recommendations from Hospice, comfort medication orders for the resident were not implemented promptly. The initial Hospice recommendation for comfort medications was made and signed by the resident's physician, but these orders were not added to the resident's medication profile for 55 days. During this period, repeated recommendations and urgent requests from Hospice staff were documented, highlighting the ongoing lack of action to ensure the resident had access to necessary comfort medications. The resident involved had severe cognitive impairment, was receiving Hospice services, and exhibited behaviors such as rejecting care and wandering. The facility's own policy required a coordinated plan of care with directives for managing pain and comfort measures, and designated staff from both the facility and Hospice were responsible for ensuring care coordination. Interviews with the Director of Nursing confirmed that Hospice recommendations should have been implemented within 24 hours, but this did not occur, resulting in a significant delay in the administration of comfort medications for the resident.
Failure to Assess and Prevent Elopement Risk for Resident with SUD
Penalty
Summary
The facility failed to ensure the safety of a resident with a history of substance use disorder, Wernicke Encephalopathy, anxiety, and depression by not assessing the resident for wandering or elopement risk upon admission. There was no nursing admission assessment, no documentation of the resident's mental or ambulation status, and no completion of the required wandering/elopement risk assessment as outlined in the facility's policy. The resident was not properly evaluated for elopement risk factors, including their medical and psychosocial history, and no individualized care interventions were implemented. The resident expressed a desire to leave the facility and was later found to have left without staff awareness. Staff interviews confirmed that the resident was not seen or assessed by nursing or social services upon admission, and the Director of Nursing acknowledged that the facility's elopement policy was not initiated when the resident was discovered missing. The lack of assessment and failure to follow established elopement prevention protocols resulted in the resident leaving the facility without appropriate supervision or response from staff.
Failure to Provide Adequate Nutritional Care and Adherence to Dietary Orders
Penalty
Summary
The facility failed to provide adequate nutritional care and services for two residents identified as being at risk for nutritional decline. For one resident with Marfan Syndrome, hemiplegia, and dysphagia, there was a significant weight loss of nearly 7% in one month. Despite this, the dietician did not implement any nutritional interventions after identifying the weight loss, citing a lack of time to consult with the Unit Manager. The resident's care plan indicated the need to notify the dietician if persistent weight loss occurred, but no action was taken until prompted by the surveyor. Another resident with a diagnosis of Diabetes Mellitus experienced a substantial weight loss and was ordered a glucose control nutritional supplement to be provided with lunch. However, staff provided the resident with a different supplement, Boost Original, which was not ordered and contained significantly more carbohydrates and sugar than the prescribed supplement. The medication administration record inaccurately documented that the resident was receiving the glucose control supplement, while observations and interviews confirmed the resident was regularly given the original supplement, sometimes in excess and without proper documentation. Staff interviews revealed a lack of understanding regarding which supplements to provide, with a CNA admitting to routinely giving the original supplement based on the resident's and visitor's preferences, without checking with nursing staff or following physician orders. The dietician was unaware that unapproved supplements were being given, which compromised the ability to accurately assess and manage the resident's nutritional and diabetic needs. The unit manager and regional nurse acknowledged that staff were not following proper procedures for supplement administration.
Failure to Accurately Monitor and Document Fluid Restriction for Dialysis Resident
Penalty
Summary
Facility staff failed to accurately monitor and document the fluid intake for a resident with End Stage Renal Disease (ESRD) who was dependent on hemodialysis. The resident was admitted with diagnoses including ESRD and required a strict fluid restriction of 1200 ml per day as ordered by the physician. Facility policies required comprehensive care planning, accurate monitoring, and documentation of fluid intake for residents on dialysis, including shift-based and daily totals, as well as coordination between nursing and dietary departments. Despite these requirements, review of the resident’s Medication Administration Records (MARs) for three consecutive months revealed that the daily fluid allotment was incorrectly set at 1800 ml instead of the physician-ordered 1200 ml. Additionally, the total daily fluid intake was not consistently calculated or documented, with numerous days missing totals each month. Interviews with nursing staff, the DON, and the Registered Dietitian (RD) confirmed that the fluid restriction order was not properly entered or monitored, and that the preset template in the facility’s electronic medical record system was incorrect and not updated to reflect the physician’s order. The lack of accurate monitoring and documentation of fluid intake, as well as the failure to follow the physician’s order for fluid restriction, placed the resident at risk for complications related to fluid overload. The facility’s own policies and staff interviews confirmed that the processes for determining, entering, and tracking fluid restrictions were not followed as required for residents receiving dialysis.
Infection Preventionist Absent from QAPI Committee Meeting
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assessment and Assurance (QAPI) Committee participated in each of the quarterly QAPI meetings. Specifically, review of attendance sheets for four consecutive quarterly meetings showed that the Infection Preventionist (IP) was not present for one of the meetings. During an interview, the Administrator confirmed that the facility did not have an IP at the time of that meeting, resulting in the absence of this required committee member.
Failure to Follow Enhanced Barrier Precautions and Maintain Medication Cart Cleanliness
Penalty
Summary
Facility staff failed to adhere to infection control standards in two key areas. First, staff did not follow physician orders and facility policy regarding Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer on the right heel. During observed wound care, two nurses entered the resident's room and performed high-contact wound care activities without donning gowns, despite clear signage and policy requiring both gloves and gowns for such procedures. Both staff acknowledged the requirement for gowns and recognized the EBP signage, but proceeded without the necessary protective equipment. The resident involved had a documented pressure ulcer and was under a care plan and physician orders that specified the use of EBP, including the posting of signage and the use of personal protective equipment during high-contact care. The infection preventionist confirmed that all residents with wounds should be on EBP and that staff had been educated on this requirement. Despite this, the observed wound care was conducted without gowns, contrary to both policy and physician orders. Additionally, the facility failed to maintain sanitary conditions for a medication administration cart on one unit. During a medication pass, the cart was found to contain dried spilled liquid, particles of medication pills, stained dried dark particles, and an old rusted scissors. The agency nurse using the cart acknowledged the potential for bacterial contamination, and the Director of Nursing confirmed the cart was dirty and in need of cleaning, but was unsure when it was last cleaned or disinfected, despite the existence of a cleaning schedule.
Failure to Administer Pneumococcal Vaccinations to Eligible Residents
Penalty
Summary
The facility failed to administer Pneumococcal vaccinations to two residents who were eligible and had provided consent for the immunization. According to the facility's own policy and CDC recommendations, residents should be offered and administered appropriate Pneumococcal vaccines unless medically contraindicated or previously immunized. In these cases, one resident had received a previous dose of PPSV23 but had not received any further recommended Pneumococcal vaccines, despite being eligible and having consented. The other resident had never received any Pneumococcal vaccine and had also provided consent, but there was no evidence of vaccine administration. Review of the residents' clinical records confirmed that both were over the age threshold for vaccination, had relevant medical conditions such as diabetes, end stage renal disease, hypertension, and chronic kidney disease, and had no medical contraindications to receiving the vaccine. The omission was acknowledged by the Regional Infection Preventionist, who confirmed that the facility missed providing the required immunizations to both residents.
Failure to Issue SNF ABN to Resident's Health Care Proxy After Skilled Coverage Ended
Penalty
Summary
The facility failed to issue the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to a resident's Health Care Proxy when the resident's Medicare Part A skilled services coverage ended. According to the clinical record, the resident was not their own responsible party, and the effective date of coverage for skilled services had expired. Despite the resident remaining in the facility and not being discharged, there was no evidence that the SNF ABN was provided to the designated Health Care Proxy. During an interview, the Clinical Reimbursement Coordinator acknowledged that the SNF ABN should have been issued to the resident's responsible party after the skilled benefit ended but confirmed that this was not done. The report also references the requirements for issuing the ABN, including the need for timely delivery, review with the beneficiary or representative, and proper documentation, none of which were met in this instance.
Failure to Accurately Code Antiplatelet Medication on MDS Assessment
Penalty
Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) assessment for one resident who had a history of aortic valve stenosis, myocardial infarction, and hypertension. The resident was prescribed enteric coated aspirin, an antiplatelet medication, as part of their physician orders. However, review of the MDS assessment showed that while the resident was coded for antianxiety, antidepressant, hypoglycemic, and anticonvulsant medications, the use of an antiplatelet medication was not coded. During an interview, the MDS nurse confirmed that the resident was receiving an antiplatelet medication and acknowledged that the MDS assessment should have reflected this, in accordance with the Resident Assessment Instrument (RAI) Manual.
Delayed Notification of Positive Influenza Result Led to Missed Antiviral Treatment
Penalty
Summary
A deficiency occurred when a resident exhibiting symptoms of influenza, including fever and cough, was not provided timely treatment due to a delay in obtaining and acting upon laboratory test results. The resident, who had a history of unspecified dementia and major depressive disorder, was tested for a respiratory panel as ordered by the nurse practitioner. The specimen was collected and resulted positive for influenza the following day, but the results were not obtained or communicated to the provider or nursing staff until six days later. Facility policy required that laboratory results be communicated to the provider and recorded in the patient record in a timely and effective manner, especially for results outside clinical reference ranges. However, the nursing staff did not check or follow up on the laboratory results promptly. The nurse who cared for the resident on the day of testing did not receive the results during her shift and did not follow up by calling the lab, assuming the results might take longer. The unit manager confirmed that results are typically received via a laboratory printer, but if unavailable, staff could call the lab. The nurse practitioner and infection preventionist were not made aware of the positive influenza result until several days later. As a result of the delay, the resident was not started on antiviral medication (Tamiflu) within the effective treatment window. The nurse practitioner stated that if she had been informed of the positive result in a timely manner, she would have initiated antiviral treatment, as the resident was symptomatic and at high risk for complications. The director of nursing acknowledged that the nurse should have checked for results the day after testing and communicated findings to the next shift if results were still pending.
Failure to Promptly Notify Provider of Positive Influenza Test Result
Penalty
Summary
Nursing staff failed to promptly notify the ordering practitioner of a positive Influenza laboratory result for a resident who was exhibiting fever, cough, and cold symptoms. The resident was swabbed for a respiratory panel, including Influenza, COVID, and RSV, as ordered by the Nurse Practitioner. The specimen was collected and the laboratory reported a positive Influenza result the following day. However, the result was not communicated to the provider until six days later, despite facility policy requiring timely notification of out-of-range laboratory results. Interviews revealed that the nurse assigned to the resident did not follow up on the test results and did not contact the laboratory when results were not received as expected. The Unit Manager and DON confirmed that nurses are responsible for checking the lab printer and following up with providers, and that the nurse should have ensured the results were obtained and communicated. The delay in notification was only discovered when the Nurse Practitioner independently obtained the results from the offsite laboratory, finding that staff were unaware of the resident's positive Influenza status and had not implemented appropriate precautions.
Failure to Maintain Complete and Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents who tested positive for Influenza. For each of these residents, there was no documentation that a physician's order was obtained to implement Droplet Precautions, as required by facility policy. Additionally, there was no documentation in the Treatment Administration Records to support that Droplet Precautions had been implemented for these residents. Interviews with facility staff revealed confusion regarding responsibility for obtaining the necessary physician's orders, with both the Unit Manager and Infection Preventionist indicating it was the nurse or Unit Manager's responsibility, respectively. Furthermore, for one resident with dementia and major depressive disorder, Certified Nurse Aide (CNA) Activities of Daily Living (ADL) Flow Sheets were found to be incomplete over multiple shifts within a specified period. Documentation for several days and shifts was left blank in all ADL care areas, despite the resident's need for various levels of staff assistance with ADLs as indicated in their Minimum Data Set (MDS) assessment. The Director of Nursing confirmed that CNAs are responsible for completing this documentation by the end of their shift.
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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