Medford Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Medford, Massachusetts.
- Location
- 300 Winthrop Street, Medford, Massachusetts 02155
- CMS Provider Number
- 225339
- Inspections on file
- 21
- Latest survey
- August 8, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Medford Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyor observation and review of facility practices. The report does not specify the actions or omissions that led to this deficiency or provide details about the residents involved.
A nurse was observed administering medications to a resident more than two hours after the scheduled time, resulting in a medication error rate of 13.33%, which exceeds the regulatory threshold. The resident involved had multiple medical conditions and was prescribed Baclofen, Depakote Sprinkles, and Furosemide, all of which were given late despite facility policy and physician orders requiring timely administration.
Staff did not follow required procedures for securing medication carts and medications, leaving carts unlocked and unattended in hallways and placing medications on top of carts while out of sight. Both a nurse and the DON confirmed that these actions were not in line with facility policy, as medications and carts must be locked and secured at all times when not attended.
A resident's bathroom was repeatedly observed with a strong urine odor, wet and sticky floors, and visible urine stains, despite regular cleaning by CNAs and housekeeping. The shower room also had a chipped toilet seat and missing wall tiles, with maintenance staff confirming the need for repairs. These issues resulted in an environment that was not clean, safe, or homelike.
Two residents did not have their MDS assessments accurately coded: one experienced a significant weight gain that was not reflected in the MDS, and another who used tobacco was not coded for tobacco use, despite documentation and observation confirming these conditions.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with diabetes, GERD, anxiety, and dementia did not have morning medications or blood sugar checks properly documented in the medical record. The resident reported not receiving medications, and staff interviews confirmed that administration was either delayed or not recorded at the scheduled times. The MAR lacked timely entries, and documentation was completed well after the medications were due.
A nurse failed to follow infection control protocols during medication administration by not performing hand hygiene before entering resident rooms, placing fingers inside a water cup, touching a bathroom door handle without hand hygiene, and removing a lidocaine patch from a resident's shoulder without gloves or subsequent hand hygiene. The DON confirmed that these actions did not meet facility expectations for infection prevention.
The facility did not ensure residents were informed of their rights, as evidenced by 22 residents at a Resident Council Meeting stating they were unaware of their rights and that these were not regularly reviewed. Facility policy required ongoing communication of resident rights, but meeting minutes and staff interviews confirmed this was not happening. Additionally, no postings of resident rights were found in key areas of the facility.
The facility failed to address recurring grievances from residents regarding call light response times, staff using cell phones, and issues with scheduled showers. Residents also expressed discomfort with staff speaking foreign languages in care areas. Despite these ongoing concerns, minimal formal grievances were documented, indicating a lack of follow-up and resolution.
The facility failed to maintain sufficient nursing staff on weekends, falling below its own minimum staffing requirements on 13 out of 18 weekend days in May and June 2024. Despite daily meetings to ensure adequate staffing, interviews with staff confirmed challenges in meeting these levels, as highlighted by the CASPER PBJ Staffing Data Report for fiscal year Quarter 2, 2024.
The facility failed to ensure proper hiring and training of CNAs, with two CNAs working over four months without certification and three CNAs working before enrolling in training. Interviews revealed non-compliance with policies, as CNAs worked without completing necessary training or certification.
The facility failed to maintain resident dignity and self-determination, as staff spoke disrespectfully to a resident, removed personal items without consent, and communicated in foreign languages in front of residents. One resident was denied cigarettes and pushed back into the facility against their wishes, while another nonverbal resident had items removed without proper communication. Multiple residents reported discomfort with staff speaking in foreign languages during care.
A facility failed to assess the use of side rails as potential restraints for a resident with severe cognitive impairment and dependency for ADLs. Observations showed the resident's bed exits were blocked by 1/2 side rails, which were not ordered by the physician. Interviews with staff confirmed no side rail assessment was conducted, and the Corporate Director acknowledged the absence of a restraint risk assessment, leading to the use of side rails that may have acted as restraints without proper evaluation.
The facility failed to conduct CORI checks for two CNAs before hiring, as required by their policies to prevent abuse, neglect, and exploitation of residents. Despite this oversight, both CNAs continued to work at the facility. The Human Resources department acknowledged the oversight during interviews.
The facility failed to implement care plans for two residents. One resident did not receive prescribed booties for paraplegia, and another, with Alzheimer's, was not evaluated by rehab after a fall, despite care plan requirements.
A resident with aphasia and vascular dementia, primarily speaking Portuguese, was not provided with necessary communication services in an LTC facility. Observations showed staff did not use a communication book or engage with the resident during care, despite facility policies requiring such measures. Interviews revealed staff reliance on the resident's family for communication, indicating a failure to implement the facility's communication policy.
A resident with moderate cognitive impairment and multiple diagnoses was not provided with the prescribed CPAP therapy at bedtime, as observed over several days. Despite the resident's requests, staff failed to apply the CPAP facemask, and there was no documentation in the MAR and TAR. Interviews with staff confirmed the oversight, acknowledging that the CPAP should have been applied according to the physician's orders.
A resident with PTSD, bipolar disorder, and schizophrenia did not have a comprehensive trauma-informed care plan developed by the facility, as required by policy. The care plan lacked specific triggers and interventions, and there was no documentation indicating the resident declined to discuss their trauma. Interviews with staff confirmed the need for such a care plan and documentation.
A facility failed to create a care plan for a resident with suicidal and homicidal ideations, despite the resident's hospitalization following an abrupt behavioral shift and threats. The resident, with a history of psychotic disorder, major depressive disorder, and anxiety disorder, expressed intentions to harm themselves and others. Interviews with staff confirmed the expectation for a care plan in such cases, highlighting a deficiency in behavioral health care provision.
A facility failed to accurately document a resident's diagnosis of chronic obstructive sleep apnea. Despite pre-admission paperwork and physician notes indicating sleep apnea, the diagnosis was not marked as active in the resident's chart. A sleep study confirmed the condition, and a CPAP machine was provided, but the oversight in documentation was acknowledged by the Unit Manager and DON.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation. During a survey, one nurse was observed making 4 medication administration errors out of 30 opportunities, resulting in a 13.33% error rate. Specifically, the nurse administered medications to a resident more than two hours after the scheduled time, despite facility policy and physician orders requiring medications to be given within one hour of the prescribed time. The medications involved included Baclofen, Depakote Sprinkles, and Furosemide, all of which were scheduled for administration at 8:00 A.M. but were given after 10:00 A.M. The resident affected had a history of cognitive communication deficit, gastroesophageal reflux disease, anemia, and anxiety. Interviews with the nurse, unit manager, and Director of Nursing confirmed that medications should be administered within one hour before or after the scheduled time, in accordance with physician orders and facility policy. The failure to adhere to these requirements led to the identified medication errors and the elevated error rate.
Failure to Secure Medication Carts and Medications
Penalty
Summary
Staff failed to store drugs and biologicals in accordance with state and federal requirements, specifically by leaving medication carts unlocked and unattended on the Pleasant View unit. On multiple occasions, a nurse was observed walking away from an unlocked medication cart, leaving it accessible in the hallway while out of sight, with residents and staff passing nearby. The surveyor was able to open the cart and access medications during these periods of inattention. The facility's policy requires that medication carts be locked and accessible only to authorized personnel, but this was not followed during the observed medication pass. Additionally, the nurse was seen removing medications from the cart and placing them on top of the cart before walking into a resident's room, leaving the medications unattended and out of sight. This occurred more than once, with both residents and staff observed walking by the unattended medications. During interviews, both the nurse and the Director of Nursing acknowledged that medication carts must be locked when unattended and that medications should not be left on top of the cart or left unsecured.
Failure to Maintain Clean and Homelike Resident and Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment on the [NAME] unit, specifically in room [ROOM NUMBER]'s bathroom and the unit's shower room. Multiple observations revealed a persistent strong urine odor in the hallway and bathroom of room [ROOM NUMBER], with urine present on the floor around the toilet, sticky and wet flooring, and a greenish stain from urine residue. Staff interviews confirmed ongoing issues with keeping the bathroom floor dry and clean, with one housekeeper noting that the bathroom tiles may be soaked with urine, making it difficult to eliminate the odor. Bathrooms were reportedly cleaned twice daily, but the problem persisted. Additionally, the shower room on the [NAME] unit was found to have a chipped toilet seat and missing tiles on the wall. The Maintenance Director acknowledged that the toilet seat should be replaced due to chipping and that the tiles needed replacement as they had been falling off the wall. These conditions contributed to the failure to provide a clean, safe, and homelike environment for residents.
Inaccurate MDS Coding for Weight Gain and Tobacco Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents. For one resident with mild cognitive impairment and psychotic disorder, a significant weight gain of over 22% in one month was documented in the medical record, but this change was not coded in section K of the quarterly MDS assessment. The Registered Dietitian acknowledged during interview that the significant weight gain should have been coded on the MDS. For another resident with a diagnosis of nicotine dependence, the use of tobacco was not coded in section J of the admission MDS assessment, despite the resident being observed smoking outside with a smoking apron and having a care plan indicating supervised smoking. The MDS Nurse confirmed during interview that the resident's tobacco use should have been coded in the MDS.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records and properly document medication administration for one resident with multiple diagnoses, including type two diabetes, GERD, anxiety, and dementia. The resident, who had moderately impaired cognition, reported not receiving morning medications and was observed with an untouched breakfast tray. Review of physician orders showed scheduled medications and blood sugar checks, but the Medication Administration Record (MAR) did not indicate that these were administered as ordered or documented at the appropriate times. Interviews with nursing staff revealed that the nurse responsible did not document the administration of the resident's morning medications in the medical record. The unit manager confirmed the lack of documentation and stated that the resident did not receive the medications as scheduled. Further review of the administration history showed that documentation of medication administration was delayed, with entries made significantly after the scheduled times. Consulting staff and the Director of Nurses both stated that medications and blood sugar checks must be administered and documented at the time of administration, which did not occur in this instance.
Failure to Implement Infection Control During Medication Administration
Penalty
Summary
Nursing staff failed to adhere to the facility's infection prevention and control program during medication administration. Specifically, a nurse was observed picking up keys to lock the medication cart and then placing two fingers inside a plastic cup of water to carry it into a resident's room. The nurse entered resident rooms on multiple occasions to administer medications without performing hand hygiene, and was also seen touching a bathroom door handle without subsequent hand hygiene. Additionally, the nurse removed a lidocaine patch from a resident's shoulder without wearing gloves and did not perform hand hygiene after the task. During interviews, the nurse acknowledged not following proper hand hygiene protocols, including not performing hand hygiene before entering resident rooms, placing fingers inside a water cup, and failing to wear gloves when removing a lidocaine patch. The DON confirmed that staff are expected to perform hand hygiene before entering resident rooms, wear gloves when coming into contact with residents, and perform hand hygiene before and after glove use. These observations and staff admissions demonstrate a failure to implement the facility's infection prevention and control policies as required.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure that residents were informed of their rights and the rules and regulations governing their conduct and responsibilities during their stay. During a Resident Council Meeting, all 22 residents in attendance reported that they were not aware of their rights and that these rights were not regularly reviewed with them. The facility's policy, dated May 9, 2024, stated that residents should be continually informed of their rights, with large print copies available in several areas. However, a review of Resident Council Meeting minutes from January to June 2024 showed no evidence of resident rights being reviewed. Interviews with staff revealed that resident rights were not typically reviewed during meetings. The Activities Director, who had been in her role since April 2024, attended only one meeting where resident rights were not discussed. Social Worker #2, who usually attended the meetings as a note taker, confirmed that resident rights were not typically reviewed. Additionally, during a tour of the first-floor unit, no postings of resident rights were found, including in areas where many residents, including the Resident Council President, resided. The Corporate Director acknowledged that residents should be aware of their rights and where to find them, indicating a lapse in ongoing communication of these rights.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately address or resolve grievances voiced by residents during monthly Resident Council meetings. The facility's grievance policy, effective June 2021, mandates that grievances should be resolved within seven days of receipt. However, concerns such as call light response times, staff using cell phones and ear buds in resident care areas, and issues with receiving scheduled showers were repeatedly raised from January to June 2024 without resolution. Additionally, residents expressed discomfort with staff speaking foreign languages in care areas, which was also a recurring issue. During interviews conducted in July 2024, residents continued to express dissatisfaction with the facility's response to their grievances. Many residents reported that call lights were not answered promptly, and some felt neglected regarding their shower schedules. Furthermore, a significant number of residents felt uneasy about staff speaking foreign languages in their presence, fearing they were being discussed. Despite these ongoing concerns, the grievance book showed minimal formal grievances filed, indicating a lack of formal documentation and follow-up on these issues. The facility's administration acknowledged the recurring nature of these grievances and the need for improved communication and resolution processes.
Insufficient Weekend Staffing in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly on weekends. The facility's own assessment indicated a minimum staffing requirement for each unit, which was not met on 13 out of 18 weekend days in May and June 2024. Interviews with staff, including a nurse and the scheduler, confirmed the difficulty in maintaining adequate staffing levels during weekends. The CASPER Payroll-Based Journal (PBJ) Staffing Data Report for fiscal year Quarter 2, 2024, also highlighted excessively low weekend staffing. The facility's staffing schedule outlined specific requirements for each unit, including the number of charge nurses, nurses, nursing aides, and CNAs needed for each shift. Despite daily meetings between the Administrator, Director of Nursing, and Unit Managers to ensure staff assignments met resident needs, the facility consistently fell short of its minimum staffing levels on weekends. This deficiency was identified through a combination of record reviews and staff interviews, indicating a systemic issue in maintaining adequate staffing levels to ensure resident safety and well-being.
Deficiencies in CNA Hiring and Training Compliance
Penalty
Summary
The facility failed to ensure proper hiring and use of Certified Nursing Aides (CNAs), resulting in deficiencies related to the employment and training of five out of seven CNAs reviewed. Two CNAs were employed for more than four months without completing the required competency evaluation program approved by the state. Specifically, CNA #5 was hired over a year ago and had not passed the CNA test, yet continued to work and provide care to residents. Similarly, CNA #2 failed the knowledge exam and continued to work beyond the four-month period without certification. Additionally, the facility employed three CNAs who had not yet enrolled in a state-approved training and competency evaluation program. CNA #4, CNA #1, and CNA #3 were all hired and worked significant hours as CNAs before beginning their CNA classes. These CNAs were scheduled and worked multiple shifts, providing care to residents without having started the necessary training program. Interviews with facility staff, including the scheduler and the administrator, revealed a lack of adherence to the facility's policies regarding CNA training and certification. The scheduler acknowledged tracking CNAs who had not completed the CNA class but admitted that CNAs should not work until enrolled in the class. The administrator confirmed that CNAs should be enrolled in the class upon hire and not work as CNAs until enrollment. The corporate director emphasized that CNAs must be suspended from work if they fail to pass the exams within four months.
Deficiencies in Resident Dignity and Communication
Penalty
Summary
The facility failed to ensure a dignified existence and self-determination for its residents, as evidenced by several incidents involving inappropriate staff interactions. One resident, who is cognitively intact but requires maximum assistance with self-care, was spoken to disrespectfully by the Activities Director. The resident was denied cigarettes and was pushed back into the facility against their wishes, leading to agitation and frustration. The Activities Director admitted to feeling guilty about her behavior, acknowledging that she should have been more patient and respectful. Another incident involved a resident who is nonverbal and dependent on staff for all self-care activities. A Corporate Nurse entered the resident's room and removed personal items without proper communication or consent. The nurse was unaware of the resident's communication needs and did not use the available communication book. The Director of Nursing confirmed that items should not be removed without consent and that appropriate communication methods should be used. Additionally, multiple residents reported feeling uncomfortable when staff spoke in languages other than English during care and in common areas. This issue was raised in Resident Council Meetings over several months. Observations confirmed that staff were speaking in foreign languages in hallways and resident rooms, which was acknowledged by the Corporate Director as inappropriate behavior in front of residents.
Failure to Assess Side Rails as Potential Restraints
Penalty
Summary
The facility failed to identify and assess the use of side rails as a potential restraint for Resident #47, who was admitted with severe protein malnutrition, dementia, restlessness, agitation, and low back pain. Observations revealed that Resident #47 was frequently found in bed with both exits blocked by 1/2 side rails, which were not ordered by the physician. The resident's most recent Minimum Data Set (MDS) Assessment indicated severe cognitive impairment and dependency for activities of daily living, requiring substantial assistance for bed mobility. Despite these observations, the facility's records did not include an assessment to determine if the use of bilateral 1/2 side rails would be a potential restraint, nor was there an interdisciplinary bed rail assessment completed. Interviews with facility staff, including a Unit Manager, a Certified Nursing Aid (CNA), and the Corporate Director, confirmed that no side rail assessment was conducted for Resident #47. The CNA noted that the side rails were longer than those used for other residents due to the resident's restlessness, suggesting they were used for safety. However, the Corporate Director acknowledged the absence of a restraint risk assessment and agreed that the side rails in use were not 1/4 rails as per the physician's orders. The facility's failure to conduct a proper assessment and adhere to physician's orders resulted in the use of side rails that may have acted as restraints without appropriate evaluation or documentation.
Failure to Conduct CORI Checks for Employees
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. Specifically, the facility did not complete a Criminal Offender Registry Information (CORI) check before hiring two employees out of the 13 employee files reviewed. One Certified Nursing Aide (CNA) was hired in August 2022, and another in March 2004, yet neither had a CORI check completed. Both CNAs continued to work at the facility, with the most recent work dates being July 2024. During interviews, the Human Resources representative confirmed that CORI checks should be completed before employment begins but could not find the checks for these two CNAs.
Failure to Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement a personalized care plan for two residents, leading to deficiencies in their care. For one resident, who was admitted with conditions including paraplegia and post laminectomy syndrome, the facility did not apply booties as per the physician's order. Observations over several days showed the resident without the prescribed booties, both in bed and in a wheelchair. Interviews with nursing staff and the Director of Nursing confirmed that the booties should have been applied according to the physician's orders, and there was no documentation indicating the resident refused to wear them. Another resident, admitted with Alzheimer's disease and vascular dementia, experienced a fall resulting in hospitalization and injuries. The care plan included a referral to rehab following the fall, but the resident was not evaluated by physical therapy until over a month later. Interviews with the Rehab Director and Corporate Director revealed that rehab referrals are typically completed within 24 hours, but this resident did not receive the necessary evaluation in a timely manner, contrary to the plan of care.
Failure to Provide Communication Services for Non-English Speaking Resident
Penalty
Summary
The facility staff failed to provide necessary communication services for a resident with significant language and communication barriers. The resident, who primarily speaks Portuguese and has conditions such as aphasia and vascular dementia, was observed multiple times without access to a communication book, which was supposed to aid in communication. Despite the facility's policy to ensure effective communication, staff members were observed not engaging with the resident or using available translation services during care activities. Observations revealed that staff members, including CNAs, did not introduce themselves or communicate with the resident during care and meal times. The resident was left without a communication book in the room, which was supposed to be used to facilitate communication. Interviews with staff indicated a lack of awareness or use of the communication book, and some staff relied on the resident's family for communication assistance, contrary to the facility's policy. Interviews with management, including the Unit Manager and the Director of Nurses, confirmed that the communication book should have been used and that staff were expected to communicate with the resident during care. The facility's policy outlined the use of translation services and communication aids, but these were not effectively implemented, leading to the resident's inability to communicate needs effectively.
Failure to Implement CPAP Orders for Resident
Penalty
Summary
The facility failed to implement a physician's order for a Continuous Positive Airway Pressure (CPAP) mask to be worn at bedtime for a resident with diagnoses including obesity, anxiety disorder, gastro-esophageal reflux disease, and primary hypertension. The resident, who had a moderate cognitive impairment, was observed multiple times sleeping without the CPAP facemask applied, and the CPAP machine was off with the facemask in a bag on the nightstand. Despite the resident's request for staff to apply the facemask, it was not done, and the CPAP was not documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June and July 2024. Interviews with staff, including a CNA, a nurse, the Unit Manager, and the Director of Nurses (DON), confirmed that the CPAP was not applied as per the physician's orders. The staff acknowledged that the CPAP should be applied at bedtime and removed in the morning, and that orders should be documented and followed. The DON stated that the facility had obtained the necessary sleep study information and ordered the CPAP machine for the resident, emphasizing that physician orders and care plans are expected to be adhered to.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for a resident with a history of trauma, specifically Post-Traumatic Stress Disorder (PTSD), bipolar disorder, and schizophrenia. The facility's policy requires that upon admission, residents with a history of trauma or PTSD should be assessed, and a care plan with individualized interventions should be developed to avoid re-traumatization. However, the review of the resident's care plan revealed that it lacked specific triggers and interventions related to the resident's PTSD diagnosis. Interviews with facility staff, including a nurse, social worker, and the Director of Nursing, confirmed that a care plan should be developed with specific triggers for residents identified with PTSD. They also stated that if a resident chooses not to discuss their trauma or identify triggers, this should be documented in the medical record. However, the review of the medical record for the resident in question did not indicate that the resident declined to discuss their trauma or identify triggers, highlighting a failure in documentation and care planning as per the facility's policy.
Failure to Implement Care Plan for Suicidal and Homicidal Ideations
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with suicidal and homicidal ideations. The resident, admitted in November 2017, had diagnoses including psychotic disorder with delusions, major depressive disorder, and anxiety disorder. On May 31, 2024, the resident exhibited an abrupt behavioral shift, yelling and striking out at staff, and expressed intentions to end their own life and harm others. This led to an order for the resident to be sent to the emergency room for further assessment. However, a review of the resident's care plans on July 9, 2024, showed no care plan addressing these ideations, despite the hospitalization. Interviews with facility staff, including a social worker and the corporate director, confirmed that the expectation was for a care plan to be initiated when a resident expresses suicidal or homicidal comments resulting in hospitalization. The absence of such a care plan for this resident constituted a deficiency in the facility's provision of necessary behavioral health care and services.
Failure to Document Sleep Apnea Diagnosis
Penalty
Summary
The facility failed to accurately document a diagnosis of chronic obstructive sleep apnea for a resident, leading to a deficiency in maintaining medical records according to accepted professional standards. The resident was admitted with multiple diagnoses, including obesity, anxiety disorder, and hypertension, and had a moderate cognitive impairment as indicated by a BIMS score of 11 out of 15. The clinical pre-admission paperwork and physician admission note both indicated a diagnosis of sleep apnea. However, this diagnosis was not accurately documented as active in the resident's chart. A sleep study performed prior to the resident's admission confirmed moderate obstructive sleep apnea, and treatment with a CPAP machine was recommended. The facility received the sleep study documentation and a new CPAP machine was sent to the facility. Despite this, the resident's plan of care and active physician orders included the use of a CPAP machine, but the diagnosis of sleep apnea was not noted as active in the resident's chart. Interviews with the Unit Manager and the Director of Nurses confirmed the oversight in documentation.
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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