Fairhaven Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Massachusetts.
- Location
- 476 Varnum Avenue, Lowell, Massachusetts 01854
- CMS Provider Number
- 225458
- Inspections on file
- 21
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Fairhaven Healthcare Center during CMS and state inspections, most recent first.
A resident with latent TB and prior hepatotoxicity from Rifampin was admitted with hospital documentation indicating Rifampin was to be stopped indefinitely and not administered. Facility policy required use of the final hospital discharge summary and two‑nurse verification for medication reconciliation, but the Nursing Supervisor relied on a preliminary discharge summary, entered Rifampin as an active order after calling the on‑call provider, and the second nurse did not verify orders against the final discharge summary. No staff documented review of the finalized discharge instructions or clarification of the Rifampin order, and the resident received two doses of Rifampin before being transferred back to the hospital with recurrent liver injury symptoms.
The facility failed to follow physician orders for three residents, including incorrect wound care dressing, lack of hand rolls for a resident with contractures, and failure to conduct 15-minute safety checks for a resident with a history of falls and suicidal ideations. Staff were unaware or did not implement the necessary care, leading to deficiencies in meeting professional standards.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen therapy and CPAP/BiPAP equipment management. A resident received oxygen without necessary filters, while another had a dusty concentrator and dirty CPAP machine. A third resident had outdated equipment and a dirty BiPAP facemask. Staff were unclear about maintenance schedules, contributing to inadequate care.
The facility failed to follow infection control practices, including improper hand hygiene and PPE use in Enhanced Barrier Precaution rooms, unsanitized glucometer use between residents, and inadequate wound care procedures. Staff acknowledged these lapses, which were observed by surveyors.
A resident's dignity was compromised when their urinary catheter bag was repeatedly left uncovered, making it visible from the hallway. Despite the facility's policy requiring privacy bags, observations showed the catheter bag was not covered, and staff confirmed it should have been.
The facility failed to develop care plans for two residents, one at risk for pressure ulcers and another with a cardiac pacemaker. Despite assessments indicating the need for a pressure ulcer care plan for a resident with incontinence, none was created. Similarly, a resident with a pacemaker lacked a comprehensive care plan, contrary to facility policy. Staff interviews confirmed the necessity of these care plans.
A resident with dysphasia and failure to thrive was left unsupervised during meals, despite being dependent on staff for all functional tasks. Observations revealed the resident attempting to eat without assistance, contrary to the care plan requiring supervision. Staff interviews confirmed the need for help, yet the resident was left alone, indicating a failure in following care protocols.
The facility failed to provide necessary treatment for two residents with pressure ulcers. One resident did not have the required soft booties on their feet as per the care plan, often due to them being in the laundry. Another resident did not receive the correct wound treatment as recommended by the wound physician, with staff unaware of the specific treatment order. These deficiencies indicate lapses in following prescribed care plans and treatment protocols.
A resident with a history of burns from hot coffee was repeatedly observed without a lid on their coffee cup, despite care plan requirements for covered cups. Staff interviews revealed a lack of communication and adherence to the care plan, resulting in a deficiency in maintaining the resident's safety.
A resident with adult failure to thrive and type 2 diabetes was admitted as continent but later became frequently incontinent. The facility failed to conduct necessary evaluations or develop a care plan for the resident's bladder incontinence, despite policy requirements. Staff confirmed the resident's incontinence and lack of a toileting plan, highlighting a deficiency in care.
A resident with dementia and lactose intolerance experienced significant weight loss over six months. Despite the dietitian's recommendations for dietary interventions, including Mighty Shakes, these were not implemented promptly. The facility's failure to follow its weight policy and communicate effectively led to continued weight loss.
A facility failed to provide appropriate dialysis care for a resident with end-stage renal disease. The resident's care plan lacked specific interventions for the dialysis access site, and there were no emergency supplies, such as a non-serrated clamp, at the bedside. Additionally, communication between the facility and the dialysis center was inconsistent, with missing entries in the resident's communication book. Staff were unaware of the need for an emergency plan or supplies, and the care plan did not specify the location of the dialysis access site.
The facility exceeded a 5% medication error rate when two nurses made errors affecting two residents. One nurse withheld medications without physician orders, and another crushed a medication against instructions. Both actions violated facility policy requiring adherence to prescriber orders.
The facility failed to ensure medications were labeled with open dates and outdated medications were not available for administration on two resident care units. Observations revealed several medications, including inhalers and nasal sprays, were opened and undated, making it impossible to determine expiration dates. Interviews with nursing staff confirmed the requirement for medications to be labeled and dated when opened.
A resident with missing teeth and difficulty eating was not provided the prescribed Mechanical Soft (Dental) Ground texture diet. Observations showed the resident received meals inconsistent with the diet order, such as toast and an uncut grilled cheese sandwich. The facility's therapeutic diets did not include ground textures, and the resident had not been screened by Speech Therapy upon admission, leading to the deficiency.
A facility failed to maintain an accurate medical record for a resident with a pressure ulcer. The resident's air mattress, ordered to be set at 165 lbs, was observed at 180 lbs on two occasions, while the Treatment Administration Record inaccurately documented it as 165 lbs. Interviews confirmed the mattress should match the resident's weight, which was 178 lbs, and highlighted incorrect documentation.
The facility failed to support residents' right to self-determination by requiring them to eat in the dining room and not delivering meals to their rooms, causing distress and difficulty for residents who preferred or needed to eat in their rooms. This policy change led to safety concerns and challenges for residents who had to transport their meals independently.
Failure to Reconcile Hospital Discharge Orders Leads to Administration of Discontinued Rifampin
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when admission medications were not accurately reconciled and transcribed. Facility policy required that all physician and authorized practitioner orders be accurately transcribed, verified by a second licensed nurse, and reconciled with the physician upon admission and after hospitalization, with discrepancies clarified immediately. Another policy required use of the official, final hospital discharge document for medication reconciliation, with the admitting nurse resolving discrepancies prior to order entry and a second nurse confirming accuracy before activating orders in the EMR. Resident #1 was admitted with diagnoses including latent tuberculosis, anemia, muscle wasting, diabetes mellitus, and acute kidney failure. The preliminary hospital discharge summary indicated a discharge diagnosis of hepatotoxicity secondary to Rifampin and stated that Rifampin was stopped due to toxicity and to remain off it indefinitely. The finalized hospital discharge summary explicitly directed that Rifampin 150 mg capsules and Ibuprofen 600 mg tablets were not to be administered. A physician’s progress note in the resident’s record also stated that the resident was to remain off Rifampin indefinitely due to hepatotoxicity. Despite these documented instructions, the resident’s MAR contained an active order for Rifampin 150 mg, three capsules once daily, and the medication was documented as administered on two days. Interviews and record review showed that the Nursing Supervisor used the preliminary discharge summary sent to the admission coordinator, saw Rifampin listed as a current medication, called the on‑call provider, verbally reviewed and reconciled the medication list, and then entered the orders into the EMR without using the finalized discharge paperwork that accompanied the resident on the actual admission date. The second nurse responsible for double‑checking admission orders did not verify the medication orders against the final discharge summary. There was no documentation that nursing staff reviewed the finalized discharge summary or clarified discrepancies related to Rifampin with the provider. The Unit Manager reported being unaware that the medications were not reconciled or transcribed accurately upon admission, even though she stated that medication reconciliation should always be completed by two nurses using the final hospital discharge summary. As a result of these failures, the resident received two doses of Rifampin after it had been discontinued at the hospital, and the resident was subsequently transferred back to the hospital with recurrent symptoms related to liver injury.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to meet professional standards of quality care for three residents, as observed by surveyors. For one resident, the facility did not apply the correct wound care dressing as per physician orders. The resident, who was at risk of developing pressure ulcers and dependent on staff for daily living activities, was observed with an incorrect silicone foam dressing instead of the prescribed collagen and bordered gauze dressing. The nurse acknowledged the error, and the Assistant Director of Nursing confirmed that staff should follow physician orders and facility protocols for wound care. Another resident, diagnosed with quadriplegia and contractures, was not provided with hand rolls as ordered by the physician. The resident's care plan did not include the use of bilateral hand rolls, and staff were unaware of the requirement. Observations showed the resident without hand rolls during the night, despite a sign indicating their necessity. Interviews with staff revealed a lack of awareness and implementation of the physician's orders regarding the hand rolls. A third resident, with a history of major depressive disorder and recent falls, was not monitored with 15-minute safety checks as ordered. The resident, who had moderate cognitive impairment and a history of suicidal ideations, was observed without staff conducting the required checks. The facility's documentation did not reflect the implementation of these checks, and staff interviews confirmed the oversight. The Director of Nursing emphasized the importance of following physician orders for the resident's safety.
Deficiencies in Respiratory Care Services
Penalty
Summary
The facility failed to provide appropriate respiratory care services for three residents, leading to deficiencies in the management of oxygen therapy and CPAP/BiPAP equipment. Resident #317, who was admitted with acute and chronic respiratory failure and type 2 diabetes mellitus, was observed multiple times receiving oxygen via nasal cannula without the necessary external filters on the oxygen concentrator. Despite the physician's order for continuous oxygen therapy, the staff, including the Unit Manager and Assistant Director of Nursing (ADON), were initially unaware of the requirement for filters, which was later confirmed by the oxygen concentrator's manual and a representative from the oxygen supply company. Resident #77, who was moderately cognitively impaired and dependent on a CPAP machine, was found to have a thick layer of dust on the oxygen concentrator filter, and the CPAP machine was visibly dirty. The oxygen tubing was undated, and the CPAP mask was improperly stored. Despite physician orders for nightly CPAP use, the staff, including Nurse #1 and Unit Manager #1, were unclear about the frequency of cleaning and changing the equipment, leading to inadequate maintenance of the respiratory equipment. Resident #42, who was cognitively intact and dependent on a BiPAP machine, was observed with outdated oxygen tubing and sterile water, a dusty concentrator filter, and a visibly dirty BiPAP facemask. The resident's physician orders required regular cleaning and changing of the equipment, but the Treatment Administration Record (TAR) showed inconsistencies in documentation and adherence to these orders. Interviews with staff, including a Certified Nursing Assistant (CNA) and Unit Manager #4, revealed a lack of compliance with the prescribed maintenance schedule, contributing to the deficiency in respiratory care for this resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control practices, as observed by surveyors. In one instance, a housekeeper entered and exited rooms requiring Enhanced Barrier Precautions without performing hand hygiene. The housekeeper also changed trash and swept floors without using gloves appropriately. Additionally, two CNAs were observed in a resident's room, who required Enhanced Barrier Precautions, without wearing the necessary gloves and gowns while providing care. The facility also failed to sanitize shared medical equipment, specifically a glucometer, between residents. A nurse was observed using the glucometer on multiple residents without cleaning it between uses, despite the facility's policy requiring sanitization after each use. Both the nurse and the Assistant Director of Nursing acknowledged that the glucometer should be sanitized after each use. During a wound dressing change, a nurse did not perform hand hygiene after removing gloves and placed dressing supplies on a resident's bed. The nurse also stored unused dressing supplies in the resident's personal drawer and wrote on the resident's dressing while it was on their body. The nurse admitted to not following proper hand hygiene and wound care protocols, which was confirmed by the Assistant Director of Nursing.
Failure to Use Privacy Bag for Urinary Catheter
Penalty
Summary
The facility failed to provide a dignified existence for a resident by not utilizing a privacy bag for the resident's urinary catheter bag, which was visible and in use. The resident, who was admitted with acute and chronic respiratory failure with hypoxia and type 2 diabetes mellitus, had intact cognition and was dependent on staff for toileting hygiene. Observations made by the surveyor on multiple occasions revealed that the urinary catheter bag, containing visible yellow urine, was hanging from the resident's bed or clipped to the wheelchair armrest and could be seen from the hallway. Despite the presence of a privacy bag next to the catheter bag on one occasion, it was not in use. Interviews with facility staff, including a nurse and the Assistant Director of Nursing, confirmed that the urinary catheter bags should have been covered with a privacy bag to prevent them from being visible from the hallway. The facility's policy on resident rights, which guarantees a dignified existence, was not adhered to in this instance, as the resident's urinary catheter bag was repeatedly left uncovered, compromising the resident's dignity.
Failure to Develop Care Plans for Pressure Ulcer and Pacemaker Management
Penalty
Summary
The facility failed to develop and implement person-centered care plans with measurable goals and individualized interventions for two residents. Resident #58, who was admitted in June 2024 with diagnoses including adult failure to thrive and type 2 diabetes mellitus, was observed without sheets on the bed and reported incontinence. Despite being at risk for pressure ulcers, as indicated by the Minimum Data Set (MDS) and Care Area Assessment (CAA), no care plan was developed to address this risk. Interviews with staff confirmed the resident's incontinence and the need for a care plan to prevent pressure injuries. Resident #94, admitted in August 2023 with a cardiac pacemaker, also lacked a comprehensive care plan for pacemaker management. The facility's policy required documentation of pacemaker details upon admission, but the resident's medical record did not reflect this. Interviews with the Unit Manager and Assistant Director of Nursing confirmed that a care plan should have been developed for the pacemaker, highlighting a lapse in care planning for this resident as well.
Failure to Provide Meal Supervision for a Resident
Penalty
Summary
The facility failed to provide necessary supervision during meals for a resident who was dependent on staff for all functional tasks. The resident, admitted with diagnoses including dysphasia and failure to thrive, was observed on multiple occasions attempting to eat meals without staff assistance. During these observations, the resident was not visible from the hallway, and no staff were present in the room to assist or supervise. The resident's care plan indicated a need for supervision with a 1:8 ratio and occasional assistance, yet this was not adhered to, as evidenced by the resident being left alone during meal times. The resident's care plan and CNA care card indicated the need for assistance with eating, including setting up meals and providing reminders. However, staff failed to follow these directives, as observed by the surveyor. Interviews with staff, including a CNA and the Director of Nursing, confirmed that the resident required help with eating and that staff were expected to follow the care plan. Despite these expectations, the resident was left unsupervised, highlighting a deficiency in the facility's adherence to care plans and supervision protocols.
Failure to Implement Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to provide necessary treatment and services for two residents with pressure ulcers. Resident #37, who has a history of chronic obstructive pulmonary disease, moderate protein calorie malnutrition, and other conditions, was observed without the required soft booties on both feet as per the medical plan of care. Despite having orders for soft booties to be worn every shift, observations showed the resident's feet were often on a pillow or directly on the mattress without the booties. Interviews with staff revealed that the booties were sometimes unavailable due to being in the laundry, indicating a lapse in ensuring the resident's care plan was followed. Resident #61, admitted with diagnoses including heart failure and chronic respiratory failure, was not receiving the correct wound treatment as recommended by the wound physician. The physician had advised using collagen with silver for a stage 3 pressure ulcer on the coccyx, but the treatment administered was collagen without silver. The discrepancy was noted during a surveyor's observation, and interviews with the nursing staff revealed a lack of awareness about the specific treatment order and its importance. The Assistant Director of Nursing acknowledged the oversight and the antimicrobial benefits of the silver in the collagen, which were not being utilized. These deficiencies highlight a failure in the facility's adherence to prescribed treatment plans and protocols for pressure ulcer management. The lack of proper implementation of care plans and treatment orders for residents at risk of or with existing pressure ulcers indicates a need for improved communication and adherence to medical directives within the facility.
Failure to Implement Safety Interventions for Resident with Burn History
Penalty
Summary
The facility failed to implement safety interventions for a resident who had previously suffered burns from spilled hot coffee. The resident, who has intact cognition and requires setup assistance with meals, was observed multiple times without a lid on their coffee cup, despite a care plan indicating the necessity of using a covered cup to prevent further burns. The resident's care plan and incident report both specified that hot liquids should be served in a covered cup, yet during several meal observations, the resident was given a mug without a lid, and no cup holder was attached to their wheelchair. Staff interviews revealed that the resident's diet slip did not indicate the need for lids with coffee, and there was a lack of communication between nursing and dietary services regarding this requirement. The Unit Manager, Assistant Director of Nursing, and Director of Nursing all acknowledged the need for lids on the resident's coffee due to their history of burns, but the necessary precautions were not consistently implemented. This oversight in following the care plan and ensuring proper communication led to the deficiency in maintaining the resident's safety.
Failure to Implement Continence Care Plan
Penalty
Summary
The facility failed to provide appropriate services to maintain continence for a resident, identified as Resident #58, who was admitted in June 2024. The resident, who has diagnoses including adult failure to thrive and type 2 diabetes mellitus, was initially assessed as continent of bladder upon admission. However, subsequent assessments indicated a decline in urinary continence, with the resident becoming frequently incontinent. Despite this change, the facility did not conduct further evaluations or develop a person-centered care plan with individualized interventions for the resident's bladder incontinence. Observations and interviews revealed that Resident #58 was often found incontinent and without a proper toileting program in place. The resident expressed that they wore briefs and did not always recognize the urge to urinate. Staff members, including CNAs and nurses, confirmed the resident's incontinence and lack of a toileting plan. The facility's policy required a 3-day observation tool and a Bladder and Bowel Evaluation to be completed upon admission, annually, quarterly, and when significant changes occur, but these were not implemented for Resident #58. Interviews with facility staff, including the Director of Nursing, indicated that the necessary assessments and care plans were not completed as required. The DON acknowledged that a new assessment should have been triggered after admission and that a quarterly evaluation and a 3-day bladder voiding trial should have been conducted to determine the type of incontinence and the potential benefit of a toileting plan. The lack of these evaluations and an individualized care plan for urinary incontinence constituted a deficiency in the facility's care for Resident #58.
Failure to Implement Dietary Interventions for Resident's Weight Loss
Penalty
Summary
The facility failed to implement necessary interventions for a resident experiencing significant weight loss. Resident #13, who was admitted with diagnoses including dementia and lactose intolerance, experienced a weight loss of 16.61% over six months. Despite the dietitian's recommendations for dietary interventions, including the use of Mighty Shakes twice daily, these were not implemented in a timely manner. The resident's weight continued to decline, and the dietitian's recommendations were not acted upon until a month later, when the order for Mighty Shakes three times daily was finally initiated. The deficiency was identified through observations, record reviews, and interviews. The facility's weight policy required reweighing and notifying the interdisciplinary team for significant weight changes, but these steps were not effectively followed. Interviews with staff, including the CNA, physician, dietitian, unit manager, and DON, revealed a lack of awareness and communication regarding the implementation of the dietitian's recommendations. This oversight contributed to the resident's continued weight loss, highlighting a failure in the facility's process for addressing significant weight changes in residents.
Deficiency in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident who required such services. The resident, who was admitted with end-stage renal disease and dependent on renal dialysis, had a chest port for dialysis access. The facility did not adhere to emergency care practices for the use of a venous catheter, as there were no emergency items, including a non-serrated clamp, in the resident's immediate area. The resident was unaware of any supplies for emergency care of the chest catheter, and the facility staff, including the nurse and unit manager, were not aware of the need for an emergency plan or supplies at the bedside. The facility also failed to have a person-centered care plan with individualized interventions for the resident. The care plan did not indicate the location of the resident's dialysis access site or include interventions related to the access site, such as having non-serrated clamps bedside for emergencies. Additionally, the physician's orders did not include the requirement for non-serrated clamps for emergencies related to the venous catheter access site. Furthermore, the facility did not ensure consistent communication between the facility and the dialysis treatment center according to the medical plan of care. The resident's communication book, which was supposed to document vital signs and any changes in condition, was missing entries for several dates in August, September, and October. The Assistant Director of Nursing acknowledged that staff should send the resident with a completed communication document for each dialysis treatment and that the dialysis care plan should specify the location of the dialysis access site.
Medication Administration Errors Exceed 5% in Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as observed during a survey. Two nurses were involved in medication administration errors affecting two residents. Nurse #3 did not administer Amlodipine and Lasix to a resident with primary pulmonary hypertension due to low blood pressure, despite lacking physician orders to withhold these medications. This decision was made without consulting a physician, which is against the facility's policy that requires medications to be administered according to prescriber orders. Nurse #4 crushed and administered Aripiprazole to a resident, despite the medication card's instructions not to crush or chew the tablet. The resident had requested the medication to be crushed, but Nurse #4 acknowledged that a physician's order is necessary for such modifications. The Unit Manager and the Assistant Director of Nursing confirmed that medication administration should adhere to physician orders and pharmacy guidelines, emphasizing the need for physician approval for any changes in medication administration.
Medication Labeling and Expiration Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly labeled with open dates and that outdated medications were not available for administration on two of four resident care units. During an observation of the [NAME] Unit medication Cart One, several medications, including ProSource Liquid Protein, fluticasone nasal spray, saline nasal spray, and various inhalers, were found opened and undated, making it impossible to determine their expiration dates. Manufacturer instructions for these medications specified discard dates after opening, which were not adhered to, indicating a lapse in following proper medication storage protocols. Similarly, on the Centerville Unit medication Cart One, additional medications such as Budesonide inhaler, ipratropium Bromide and albuterol sulfate, Dorzolamide eye solution, and Tuberculin Purified Protein Derivative were also found opened and undated. Interviews with nursing staff, including a nurse, a unit manager, and the Director of Nursing, confirmed that medications should be labeled and dated when opened, and expired medications should not be present in the medication cart. This oversight in medication management reflects a failure to comply with the facility's policy on medication storage and preparation.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide the prescribed therapeutic diet for a resident who was admitted with diagnoses including acute and chronic respiratory failure with hypoxia and type 2 diabetes mellitus. The resident was prescribed a Mechanical Soft (Dental) Ground texture diet due to missing teeth and difficulty eating certain foods. However, the resident did not receive the appropriate ground textures during meals, as observed by the surveyor. The resident expressed difficulty eating bread due to missing teeth, and the surveyor noted that the resident's breakfast included toast, which the resident could not eat. Further observations revealed that the resident's lunch included an uncut grilled cheese sandwich with crust, which was not in line with the prescribed ground texture diet. The facility's Food Service Director and Registered Dietitian confirmed that the meal did not meet the ground texture requirement. The facility's therapeutic diets did not mention ground textures, and there was confusion about the resident's diet order. The resident had not been screened by Speech Therapy upon admission to the facility, which contributed to the oversight in providing the correct diet.
Inaccurate Medical Record and Equipment Setting
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident who was admitted in July 2023 with a diagnosis that included a pressure ulcer in the sacral region. The resident's Minimum Data Set (MDS) indicated moderate impaired cognition and the presence of a pressure ulcer. Physician orders from December 2023 required a specialty air mattress to be set at 165 lbs and checked every shift to aid in wound healing. However, observations on two consecutive days in October 2024 revealed the air mattress was set at 180 lbs, contrary to the physician's orders. Despite this discrepancy, the Treatment Administration Record (TAR) for October 2024 showed that nurses inaccurately documented the mattress setting as 165 lbs. Interviews with the Unit Manager and Assistant Director of Nursing confirmed that the mattress should be set according to the resident's weight, which was 178 lbs, and that the documentation in the TAR was incorrect.
Failure to Support Resident Self-Determination in Meal Choices
Penalty
Summary
The facility failed to support residents' right to self-determination by not facilitating their choice to eat meals in their rooms. A notification letter was issued to all residents, indicating that they were required to eat in the dining room unless they were ill or had approval from nursing staff. Additionally, the letter stated that nursing staff would no longer deliver meal plates to residents' rooms, forcing some residents to transport their meals themselves, even if they had approval to eat in their rooms. This policy change was not communicated in a timely manner, causing distress among the residents who felt their rights were being infringed upon. During a tour, a surveyor observed a resident using a rolling walker to transport a meal plate to their room, without any assistance from the nursing staff present in the hallway. The resident expressed difficulty and frustration with this process, citing challenges in balancing hot food items and beverages on the walker. Another resident, who preferred to eat in their room due to anxiety, also had to transport their meal using a cane, which they found hard but necessary to avoid the dining room. Both residents were independent in mobility and eating but faced significant challenges due to the facility's policy. Interviews with staff, including the Director of Nursing (DON) and the Director of Social Services, revealed concerns about the safety and homelike environment of the facility. The DON acknowledged that residents should feel at home and have the right to eat their meals wherever they choose. However, the facility's administration implemented the policy to address pest control issues, as reported by their pest control company. The administration's decision to require residents to transport their meals independently, even if they had approval to eat in their rooms, led to the observed deficiencies in supporting residents' rights and ensuring their safety and comfort during mealtimes.
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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