Life Care Center Of Auburn
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Massachusetts.
- Location
- 14 Masonic Circle, Auburn, Massachusetts 01501
- CMS Provider Number
- 225661
- Inspections on file
- 21
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Life Care Center Of Auburn during CMS and state inspections, most recent first.
A resident who was initially admitted with depression and a negative PASRR screen later developed delusional disorders and hallucinations, leading to the initiation of antipsychotic medication. Despite these significant changes in mental health status, the facility did not refer the resident to the PASRR Office for a required Resident Review.
A resident with chronic heart failure and other serious conditions developed new bilateral lower extremity edema that was not identified or assessed in a timely manner. Despite visible swelling and the resident's report of new symptoms, staff did not notify nursing, and the assigned nurse failed to assess or document the change. The delay in assessment and lack of communication led to the resident's edema remaining unaddressed for several days.
Two residents requiring Enhanced Barrier Precautions for indwelling urinary catheters did not receive care in accordance with infection control protocols. In both cases, staff performed hands-on catheter assessments wearing only gloves, omitting the required gown, and in one instance, failed to perform hand hygiene before donning PPE. These actions were contrary to facility policy and CDC guidelines, as confirmed by staff interviews and posted signage.
The facility did not accurately complete MDS assessments for two residents. One resident receiving hospice care was not coded as such on the MDS, despite having a physician's order and being admitted to hospice. Another resident transferred to the hospital for an acute health change was incorrectly coded as 'discharge return not anticipated,' even though staff expected the resident to return. These inaccuracies were confirmed by the MDS nurse.
The facility failed to follow its Abuse Prohibition Policy when two residents reported allegations of inappropriate conduct by a housekeeper. One resident, with intact cognitive patterns, reported being kissed on the cheek, while another, with moderately impaired cognition, reported inappropriate contact. Staff did not immediately report these allegations to supervisors, violating facility policy.
The facility failed to report allegations of abuse involving two residents to the DPH. In one case, a CNA found a housekeeper alone with a cognitively impaired resident in a bathroom, but the incident was not reported. In another case, a resident expressed feeling stalked by the housekeeper, but the DON concluded the resident felt safe and did not report it. These actions violated mandatory reporting requirements.
The facility failed to thoroughly investigate allegations of potential sexual abuse involving two residents. In one case, a resident with cognitive impairment was found alone in a bathroom with a housekeeper, but no physical assessment or interviews were documented. In another case, a resident expressed feeling stalked by the same housekeeper, yet the investigation lacked necessary documentation and interviews. The facility did not adhere to its policies on abuse investigation and response.
The facility failed to provide care consistent with professional standards to prevent and treat a pressure ulcer for a resident with a high risk of developing pressure ulcers due to a history of diabetes and peripheral vascular disease. The resident was provided an orthopedic surgical shoe, but the facility staff failed to assess its fit and use, leading to the development of ulcers. The staff did not implement timely treatments or skin assessments, resulting in further skin breakdown.
A resident with peripheral vascular disease and a chronic ulcer experienced severe pain during a dressing change because the nurse did not offer pain medication beforehand. Despite the resident's known sensitivity and history of severe pain, the nurse proceeded with the procedure, causing significant distress. Interviews confirmed that the resident should have been assessed and medicated for pain prior to the dressing change.
The facility failed to notify the NPP of a resident's significant weight loss, delaying medical evaluation. Despite monitoring and confirming severe weight loss, the NPP was not informed until weeks later, contrary to the care plan and NPP's request.
A resident with a history of weight loss experienced severe weight loss due to the facility's failure to obtain weekly weights, monitor weights as recommended, coordinate care among the interdisciplinary team, and evaluate causative factors. Despite the resident's good appetite and requests for additional food, the staff did not consistently perform weight monitoring or alert the physician to the severe weight loss.
The facility failed to ensure staff adhered to infection control standards for four residents on two units. Staff did not wear appropriate PPE during nephrostomy and wound care for a resident on Enhanced Barrier Precautions and did not perform proper hand hygiene for two residents, one of whom was on Contact Precautions for C. difficile.
The facility failed to provide the correct topical wound medication as ordered by the Physician for a resident, resulting in the removal and re-application of the dressing, causing additional discomfort. The resident had specific orders for Silver Sulfadiazine for the left foot wound and Santyl for the left heel wound, but Nurse #1 incorrectly applied both medications to both wounds.
The facility failed to schedule a necessary Urology consultation for a resident with an indwelling urinary catheter, despite a physician's order. The resident developed a ventral erosion of the genitalia, and the appointment was not scheduled until prompted by a surveyor, leading to a delay until August 2024.
The facility failed to ensure that a nurse had the necessary competencies for pain management and wound care, resulting in severe pain and improper treatment for a resident with peripheral vascular disease and a chronic ulcer. The nurse did not offer pain medication before a dressing change and did not follow the physician's orders, leading to significant discomfort for the resident. The facility lacked proper training and competency assessments for the nurse.
The facility failed to adhere to food service safety standards, with dietary staff not wearing proper hair restraints and a CNA improperly reheating a resident's meal without checking the temperature. The Food Service Director acknowledged the lapses in following the facility's policies.
The facility failed to accurately complete, encode, and transmit MDS Assessments for three residents. One resident's Discharge MDS Assessment was not transmitted within the required timeframe, another resident's Death in Facility Tracking Record was not completed, and a third resident's Discharge MDS Assessment was completed six days past the due date. The MDS Nurse confirmed these deficiencies.
Failure to Notify PASRR Office After Significant Change in Mental Condition
Penalty
Summary
The facility failed to promptly notify the state mental health authority (PASRR Office) of the need for a Resident Review when a resident experienced a significant change in mental condition from their initial Level I PASRR. The resident was originally admitted with a diagnosis of depression and had a negative screen for serious mental illness, with no Level II PASRR evaluation indicated at admission. During the stay, the resident developed new diagnoses of Delusional Disorders and Hallucinations, and was started on antipsychotic medication (Seroquel) following behavioral health evaluations and physician orders. Despite these significant changes, including the addition of new mental health diagnoses and the initiation of antipsychotic treatment, the clinical record did not show any evidence that a referral to the PASRR Office for Resident Review was made. This was confirmed during an interview with the facility's Social Worker, who acknowledged that the resident should have been referred for a Resident Review at the time of the new diagnoses and medication changes.
Failure to Timely Identify and Assess New Onset Edema in Resident with Heart Failure
Penalty
Summary
A deficiency occurred when staff failed to identify and assess the new onset of bilateral lower extremity edema in a resident with chronic heart failure, chronic kidney disease, hypertension, atrial fibrillation, and a malignant neoplasm of the pancreas. The resident was admitted for palliative care and had no edema upon admission, as documented in the initial nursing assessment and confirmed by a nurse practitioner. The facility's policy required regular inspection and monitoring for edema in residents with heart failure, but this was not followed. The resident began experiencing swelling in both lower extremities, which was observed by the surveyor and reported by the resident as a new development. Despite visible signs of swelling and the resident's own report of the issue, the certified nurse aide who assisted with bathing did not notify nursing staff, believing the swelling was not new. The assigned nurse was unaware of the edema and did not assess or document the change in condition. There was no evidence in the clinical record that an assessment of the edema was performed in a timely manner after the onset of symptoms. Multiple interviews revealed that neither the physician nor the physician assistant assessed the resident promptly after being notified of the swelling. The nurse responsible for the resident did not complete a required nursing note or health status note regarding the change in condition. The delay in assessment and lack of timely communication and documentation resulted in the resident's edema going unaddressed for several days, contrary to facility policy and standard care expectations for residents with heart failure.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to infection control standards of practice for two residents who required Enhanced Barrier Precautions (EBP) due to the presence of indwelling urinary catheters. For one resident with Alzheimer's Disease and neuromuscular dysfunction of the bladder, a nurse did not perform hand hygiene before donning gloves and entering the resident's room, and only wore gloves—omitting the required gown—while performing a hands-on assessment of the urinary catheter. The nurse later acknowledged not following the EBP signage, and the unit manager confirmed that a gown was required for any hands-on catheter care. For another resident with incomplete paraplegia and neuromuscular dysfunction of the bladder, a unit manager performed hand hygiene, donned gloves only, and entered the resident's room to assess the indwelling urinary catheter. The unit manager did not wear a gown as required by the EBP signage for catheter care. Upon review, the unit manager acknowledged that a gown should have been worn during the procedure to prevent potential contamination. Both incidents were observed by surveyors and confirmed through interviews and review of facility policy and CDC guidelines. The facility's own policy and posted signage indicated that both gloves and gowns were required for high-contact care activities involving indwelling medical devices, such as urinary catheters, under EBP. The failure to follow these protocols was directly observed and acknowledged by the staff involved.
Inaccurate MDS Assessments for Hospice and Discharge Status
Penalty
Summary
The facility failed to complete accurate Comprehensive Minimum Data Set (MDS) assessments for two residents out of a sample of 30, as identified through record reviews and staff interviews. For one resident with multiple sclerosis and dementia, who was severely cognitively impaired and had an invoked health care proxy, the facility did not accurately code for hospice services on the MDS, despite the resident having a physician's order for hospice and being admitted to hospice services during the assessment period. The MDS nurse confirmed that hospice services should have been coded but were not, resulting in an inaccurate assessment that did not reflect the resident's status. For another resident with hypertension and atrial fibrillation, the facility failed to accurately code the discharge status on the MDS. The resident experienced an acute change in health status, was unresponsive with abnormal vital signs, and was transferred to the hospital for evaluation. Although the facility expected the resident to return at the time of transfer, the MDS was coded as 'discharge return not anticipated.' The MDS nurse acknowledged that the coding was inaccurate, as the correct code should have been 'discharge return anticipated' based on the circumstances at the time of transfer.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to adhere to its Abuse Prohibition Policy when allegations of abuse involving two residents were not immediately reported to the appropriate supervisory staff. Resident #2, who had intact cognitive patterns, reported an incident where Housekeeper #1 kissed him/her on the cheek to Housekeeper #2. However, Housekeeper #2 did not report this allegation to her immediate supervisor or the Administrator until after being prompted by a surveyor. This delay in reporting violated the facility's policy, which mandates immediate reporting of suspected abuse. In another incident, Resident #3, who had moderately impaired cognitive patterns, allegedly experienced inappropriate contact from Housekeeper #1, as reported by a family member to Nurse #2. Despite this report, Nurse #2 failed to clearly communicate the allegation to the appropriate supervisory staff, as neither Unit Manager #2, Unit Manager #3, nor the Assistant Director of Nursing received the report. This lack of communication and failure to follow the facility's policy resulted in a deficiency in handling and reporting allegations of abuse, neglect, and theft.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the Department of Public Health (DPH) as required by their policy. In the first case, a certified nurse aide (CNA) found a housekeeper alone in the bathroom with a resident who had severely impaired cognitive patterns. The CNA reported this to the nursing staff, including the Director of Nursing and the Administrator. Despite initiating an internal investigation, the Director of Nursing and the Administrator did not report the incident to the DPH, as they did not perceive it as an allegation of abuse. In the second case, a resident with intact cognitive patterns expressed concerns to a CNA and an Occupational Therapy Assistant about feeling stalked and uncomfortable due to the housekeeper's behavior. These concerns were reported to the Director of Nursing, who conducted an investigation and concluded that the resident felt safe and comfortable, thus deciding not to report the incident to the DPH. The facility's failure to report these allegations to the appropriate authorities constitutes a deficiency in adhering to mandatory reporting requirements.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following allegations of potential sexual abuse involving two residents. For the first resident, who was cognitively impaired, a Certified Nurse Aide (CNA) discovered the resident alone in a bathroom with a housekeeper. The CNA reported the incident to the nursing staff, including the Director of Nursing (DON) and the Assistant Director of Nursing. However, the investigation lacked a documented physical assessment of the resident by a nurse and did not include interviews with the housekeeper or other staff present at the time of the incident. The internal investigation report also failed to document any interviews with the resident's representative. In the case of the second resident, who had intact cognitive patterns, the resident expressed concerns about the same housekeeper's behavior, feeling stalked and uncomfortable. These concerns were reported by a CNA and an Occupational Therapy Assistant to the DON. Despite the resident's expressed fear and anxiety, the facility's investigation did not include a documented physical assessment by a nurse or interviews with the housekeeper, other staff, or the resident's representative. The internal investigation report only included a written statement from the DON, indicating that the resident later stated feeling safe and comfortable. The facility's policies on abuse investigation and response were not adhered to, as evidenced by the lack of comprehensive documentation and assessments. The policies required prompt and thorough investigations, including physical examinations or psychosocial assessments of alleged victims and interviews with all involved parties. The facility's failure to document these critical steps in both cases highlights a significant deficiency in their handling of abuse allegations.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent and treat a pressure ulcer for a resident with a high risk of developing pressure ulcers due to a history of diabetes and peripheral vascular disease. The resident was admitted with diagnoses including diabetes with neuropathy and peripheral vascular disease. The resident was dependent on staff for putting on and taking off footwear and required assistance with various activities of daily living. Despite being at risk for pressure ulcers, the resident did not have any pressure ulcers upon admission but had two venous and arterial ulcers. The facility's policy required regular skin observations and timely treatment for any skin breakdown, but these were not adequately followed for this resident. The resident was provided an orthopedic surgical shoe on the right foot after experiencing significant pain and a loud crack while ambulating. Despite the x-ray being negative, the resident continued to experience pain and was given the surgical shoe for support. However, the facility staff failed to assess the fit and use of the orthopedic surgical shoe, which led to the development of ulcers on the right plantar foot, back of the right ankle, and right heel. The resident continued to wear the surgical shoe until after an orthopedic appointment, during which the ulcers were identified. The facility staff did not implement any physician orders for treatments immediately after the ulcers were identified, and the resident's skin was not assessed until several days later during the facility's weekly skin rounds. Interviews with the Director of Nurses, a nurse, and a Physician Assistant revealed that the facility staff did not follow proper procedures for assessing and treating the resident's skin breakdown. The orthopedic surgical shoe was not removed at night, and the resident remained in the shoe throughout the night, causing further pain and skin breakdown. The Physician Assistant noted that the facility staff should have done an assessment to ensure the shoe was not too tight and that the resident should only wear the shoe when out of bed. The lack of timely skin assessments and appropriate treatment led to the development and worsening of the resident's pressure ulcers.
Failure to Provide Appropriate Pain Management During Dressing Change
Penalty
Summary
The facility failed to provide appropriate pain management for a resident during a painful dressing change procedure. The resident, who was admitted with peripheral vascular disease and a non-pressure chronic ulcer, experienced severe pain during the dressing change. Despite the resident's known sensitivity and history of severe pain, the nurse did not offer pain medication prior to the procedure, resulting in the resident experiencing significant distress and pain rated as nine out of ten during the dressing change. The facility's policy on pain management requires that pain relief be anticipated and provided in accordance with professional standards of practice. However, during the observed dressing change, the nurse did not inform the resident about the procedure in advance or offer pain medication beforehand. The resident expressed that the pain medication would take too long to work and endured the procedure in significant pain, crying and wincing throughout. Interviews with the nurse and the Director of Nurses confirmed that the resident should have been assessed and medicated for pain prior to the dressing change. The resident's pain was not adequately managed, as evidenced by the resident's high pain levels during and after the procedure. The nurse practitioner also noted the resident's sensitivity and the expectation that pain management should have been provided before the dressing change.
Failure to Notify NPP of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Physician/Non Physician Practitioner (NPP) of a significant change in physical status for a resident, resulting in a lack of medical evaluation of the resident's status relative to weight loss. Specifically, the facility staff did not inform the NPP of the resident's severe weight loss, which was greater than five percent in one month and greater than seven point five percent in three months. This failure occurred despite the NPP's request to be notified if the severe weight loss was verified. The resident's weight was monitored and recorded multiple times, showing a significant decrease, but the NPP was not informed until much later, delaying potential medical intervention. The resident, who was admitted to the facility with diagnoses including diverticulitis and dysphagia, had a history of weight loss and was at increased nutritional risk. The resident's care plan included goals to maintain a stable weight and instructions for staff to report significant weight loss to the physician. Despite these instructions, the resident's severe weight loss was not communicated to the NPP in a timely manner. The resident's weight records showed a drop from 189.9 lbs to 173.8 lbs over a few months, indicating severe weight loss, but the NPP was not notified until weeks later. Interviews with the Registered Dietician (RD) and the NPP revealed that the RD had been monitoring the resident's weight loss since February and had recommended weekly weight monitoring. The NPP had ordered weekly weights and requested to be notified if the severe weight loss was confirmed. However, despite re-weighs confirming the severe weight loss, the NPP was not informed until April, which delayed the medical evaluation and potential treatment for the resident's condition.
Failure to Monitor and Address Severe Weight Loss
Penalty
Summary
The facility failed to provide adequate nutrition care and services for a resident with a history of weight loss. Specifically, the staff did not obtain weekly weights as ordered by the physician, monitor weights weekly as recommended by the registered dietician (RD), coordinate care among the interdisciplinary team (IDT), or evaluate causative factors for the resident's severe weight loss. The resident experienced significant weight loss over several months, which was not properly addressed by the facility staff. The resident, who was admitted with diagnoses including diverticulitis and dysphagia, had a care plan indicating increased nutrition risk and a history of weight loss. Despite this, the resident's weight was not consistently monitored, and significant weight loss was not reported to the physician. The resident's weight dropped from 191 pounds to 173.8 pounds over several months, indicating severe weight loss. The RD requested re-weighs and weekly monitoring, but these were not consistently performed, and the physician was not alerted to the severe weight loss. Observations and interviews revealed that the resident continued to have a good appetite and often requested additional food. However, the facility staff failed to follow through with the necessary weight monitoring and communication with the physician. The resident's weight was not obtained for three consecutive weeks, and the NPP was not alerted to the severe weight loss until prompted by the surveyor. This lack of coordination and communication among the facility staff led to the resident's severe weight loss not being properly evaluated or addressed.
Failure to Adhere to Infection Control Standards
Penalty
Summary
The facility failed to ensure that staff adhered to infection control standards for four residents on two out of three units observed. Specifically, staff did not wear appropriate Personal Protective Equipment (PPE) while performing nephrostomy and wound care for a resident on Enhanced Barrier Precautions (EBP) on the Primrose Unit. The nurse only wore gloves and did not wear a gown as required by the facility's policy. The nurse acknowledged the mistake during an interview. Another resident on the Magnolia Unit, who was also on EBP, did not receive proper care as the nurse failed to wear a gown while measuring the resident's foot wounds. The nurse admitted to the oversight during an interview. The facility's policy clearly indicated that both gloves and gowns were necessary for high-contact resident care activities, which were not followed in these instances. Additionally, the facility did not perform appropriate hand hygiene for two residents housed in the same room, one of whom was on Contact Precautions due to C. difficile. The housekeeper used alcohol-based hand rubs (ABHR) instead of soap and water, which is ineffective against C. difficile spores. The housekeeper and the Unit Manager were unaware of the correct hand hygiene protocol, and the signage outside the room incorrectly indicated the use of ABHR.
Incorrect Wound Medication Application
Penalty
Summary
The facility failed to provide the correct topical wound medication as ordered by the Physician for one resident, resulting in the removal and re-application of the dressing, causing additional discomfort to the resident. The resident, who was admitted with peripheral vascular disease and a non-pressure chronic ulcer, had specific orders for wound care that were not followed. The Physician's orders required Silver Sulfadiazine for the left foot wound and Santyl for the left heel wound. However, during a dressing change, Nurse #1 incorrectly applied both Santyl and Silver Sulfadiazine to both wounds, contrary to the Physician's orders. The error was observed by a surveyor and confirmed through interviews with Nurse #1 and the Unit Manager. Nurse #1 acknowledged the mistake and informed the Unit Manager. The Physician confirmed that using both medications on the same wound is counterproductive to healing. The facility's policy and procedures for wound care were not adhered to, leading to the deficiency in providing appropriate treatment and care according to the resident's needs and Physician's orders.
Failure to Schedule Urology Consultation for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide necessary services and assistance for a resident with an indwelling urinary catheter to obtain a specialist consultation with a Urologist. The resident, who was admitted with diagnoses including neuromuscular dysfunction of the bladder and urine retention, developed a ventral erosion of the genitalia. Despite a physician's order on 2/2/24 for the resident to be seen by a Urologist, the facility did not schedule the appointment until 4/9/24, after the surveyor's inquiry. The resident had not been seen by a Urologist at any time since the order was given, and the appointment was delayed until August 2024. Observations by the surveyor noted the resident's catheter tube exiting the pant leg and draining into a urine collection bag. The resident reported occasional aching pain in the genitalia but had not seen a specialist for the urinary catheter. Medical records staff and the Director of Nurses confirmed that the appointment should have been scheduled when the order was obtained, but it was not done until prompted by the surveyor. The facility's failure to schedule the necessary specialist consultation in a timely manner led to the deficiency noted in the report.
Inadequate Pain Management and Wound Care Competency
Penalty
Summary
The facility failed to ensure that Nurse #1 had the specific competencies and skills necessary to provide appropriate pain management and perform wound care for Resident #18. This resulted in poor pain control and improper wound treatment, potentially compromising the resident's healing process. The resident, who was admitted with peripheral vascular disease and a non-pressure chronic ulcer, experienced severe pain during a dressing change procedure due to the nurse's lack of competency in pain management and wound care techniques. During the dressing change, Nurse #1 did not offer pain medication to the resident beforehand, despite the resident's history of severe pain. The resident expressed significant discomfort and pain during the procedure, which was not adequately managed by the nurse. Additionally, Nurse #1 did not follow the physician's orders for wound treatment, applying incorrect medications and failing to perform the procedure as prescribed. The facility's records indicated that Nurse #1 had not received proper training or competency assessments in pain management or wound care. The Staff Development Coordinator confirmed that there was no documented evidence of such training, and the facility had not implemented a skills checklist for newly hired nurses. The Director of Nurses and the Administrator were also unaware of the specific training and competency requirements for Nurse #1, highlighting a systemic issue in the facility's staff training and competency evaluation processes.
Failure to Adhere to Food Service Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards of practice for food service safety in the main kitchen and for one resident. Specifically, three dietary staff members did not wear hair restraints while working in the food preparation and service areas, increasing the risk of food contamination. Dietary Staff #3 and #4 were observed without hair restraints while handling food, and Dietary Staff #2 wore an improperly placed hair restraint, leaving large amounts of hair exposed. The Food Service Director and Assistant Food Service Director acknowledged that hair restraints were required and that the staff should have been wearing them as per the facility's policy. Additionally, the facility failed to reheat a resident's meal in a safe and appropriate manner. Resident #86, who has Alzheimer's disease, had their breakfast meal reheated by a CNA in a microwave without checking the temperature to ensure it reached the required 165 degrees Fahrenheit. The CNA admitted to not knowing the proper reheating procedure and used a hand-over method to check if the food was warm. The Food Service Director stated that nursing staff typically call the main kitchen for a new tray if food needs to be reheated and was unaware that staff were using the microwave to reheat resident meals.
Failure to Accurately Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to accurately complete, encode, and transmit Minimum Data Set (MDS) Assessments as required for three residents out of a total sample of 25 residents. Specifically, the facility did not electronically transmit a Discharge MDS Assessment for one resident within 14 days of completing the assessment. Another resident's Death in Facility Tracking Record was not completed when the resident expired at the facility. Additionally, a Discharge MDS Assessment for a third resident was not completed within 14 days of the resident's discharge from the facility when the return was not anticipated. Resident #101, diagnosed with Congestive Heart Failure, was discharged from the facility, but the MDS Discharge Assessment was not transmitted to CMS within the required timeframe. Resident #164, diagnosed with Hypertension, expired at the facility, but no Death in Facility Tracking Record was completed. Resident #131, diagnosed with Spinal Stenosis, was discharged, but the MDS Discharge Assessment was completed six days past the due date. The MDS Nurse confirmed these deficiencies and acknowledged the importance of timely completion and processing of MDS data.
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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