Oakhill Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Middleboro, Massachusetts.
- Location
- 76 North Street, Middleboro, Massachusetts 02346
- CMS Provider Number
- 225145
- Inspections on file
- 21
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Oakhill Healthcare during CMS and state inspections, most recent first.
The facility failed to address and document grievances from two residents, who reported unresolved issues with room conditions and staff interactions. The grievance policy was not followed, as forms were not completed, and there was no documentation of investigations or resolutions. Additionally, grievance forms were not accessible to residents, preventing anonymous submissions.
The facility failed to complete and accurately assess the cognitive patterns and pain evaluation sections of the MDS for several residents. Despite indications that the Brief Interview for Mental Status (BIMS) and pain assessments should be conducted, these sections were left incomplete, affecting residents with various diagnoses such as dementia and spinal stenosis. Staff interviews confirmed the oversight in completing these assessments.
The facility failed to maintain sufficient staffing levels on weekends, as indicated by a one-star staffing rating and excessively low weekend staffing data. Interviews with residents and staff revealed delays in call light responses and frequent call-outs, particularly on weekends. The facility's staffing ratios were not consistently met, with discrepancies between the Healthcare Facility Assessment and actual staffing practices, impacting resident care.
The facility failed to follow food safety and sanitation standards, risking foodborne illness among residents. A dietary aide was observed handling ready-to-eat food without proper hand hygiene, using the same gloves for multiple tasks. Additionally, food products in nourishment kitchenettes were not properly labeled or dated, contrary to facility policy. Interviews confirmed non-compliance with established guidelines.
The facility failed to maintain accurate medical records for several residents, leading to discrepancies between residents' wishes and their EMR. Two residents had mismatched Physician's orders and MOLST forms, while another lacked a current court-approved treatment plan for antipsychotic medications. Additionally, there was a significant gap in documented physician visits for a resident, and a Level 2 PASARR was missing from a resident's medical record.
The facility failed to explain binding arbitration agreements to two residents with cognitive impairments, resulting in their signing without understanding. The Administrator was unaware of the signed agreements, and nursing staff did not provide detailed explanations during the admission process. The deficiency highlights a lack of proper procedure and communication regarding arbitration agreements.
The facility's QAPI Committee failed to include required members at meetings, with the Medical Director missing the last two quarterly meetings and the lab and pharmacy providers absent from all four meetings in 2024. Despite being invited, these members did not attend, and the Administrator was unaware of the requirement for their quarterly attendance.
The facility failed to maintain an effective infection prevention and control program, as staff did not use appropriate PPE for Enhanced Barrier Precautions (EBP) with two residents diagnosed with MRSA. Additionally, the facility lacked a specific water management plan to address Legionella risk, as confirmed by the Director of Maintenance and the Administrator.
The facility failed to provide two residents with summaries of their baseline care plans. One resident with severe cognitive impairment and an activated healthcare proxy was not informed about their care goals or provided a care plan summary. Another resident, who was alert and oriented, was not involved in a meeting to discuss their treatment plan or offered a care plan summary. Staff interviews confirmed that the required process for baseline care plans was not followed.
A facility failed to update a resident's care plan to reflect the indefinite activation of their Health Care Proxy (HCP). The resident, with chronic obstructive pulmonary disease and respiratory failure, had their HCP activated for 30 days, but the care plan was not revised despite changes in medical orders and hospice admission. The physician admitted forgetting to update the care plan, and staff confirmed it should have reflected the extended HCP activation.
The facility failed to meet professional standards of care for three residents. An RN did not document a death pronouncement, a resident with a pressure injury did not receive timely wound care adjustments, and another resident was transferred to the hospital without a physician's order. These deficiencies highlight lapses in documentation and adherence to care protocols.
A resident was observed smoking unsupervised in the courtyard without protective equipment, contrary to the facility's smoking policy. The resident's smoking evaluations were incomplete, and their care plan lacked individualized interventions. Despite receiving a nicotine patch for smoking cessation, the resident continued to smoke occasionally with family, highlighting inconsistencies in the facility's implementation of smoking policies.
A facility failed to maintain a resident's oxygen concentrator in a sanitary manner, as it was observed running without a filter on multiple occasions. The resident, who required continuous oxygen therapy due to chronic obstructive pulmonary disease and respiratory failure, had physician's orders for specific oxygen settings and tubing changes. Staff confirmed the absence of the filter, noting the concentrator model was unfamiliar to the facility.
The facility failed to create individualized, trauma-informed care plans for two residents with a history of trauma. Despite ongoing psychological services, specific triggers were not identified, and care plans were not individualized. Staff interviews revealed a lack of awareness regarding the residents' trauma histories and triggers, indicating a failure to adhere to the facility's trauma-informed care policy.
A resident with multiple diagnoses was not seen by a physician at the required intervals, resulting in a 210-day gap between visits. The facility's policy and regulatory standards were not followed, as confirmed by interviews with the physician and DON.
The facility failed to document and act on monthly medication regimen reviews (MRR) for two residents. MRRs were not included in the medical records, and recommendations were not acted upon timely. The DON kept MRRs in a binder, contrary to policy requiring documentation in the active record.
The facility failed to properly store controlled substances and left medications unsecured. A controlled substance storage box in a refrigerator was not permanently affixed, allowing removal of the shelf with the box attached. Additionally, a nurse left medications unattended on a cart without supervision, violating facility policy.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to ensure that residents had the right to voice grievances and have those grievances addressed and resolved promptly. Two residents, who were cognitively intact, reported that their grievances were not documented or resolved. One resident expressed concerns about a malfunctioning air conditioner in their room, which was not addressed despite being reported to the Administrator. Another resident reported poor customer service from nurse aides, but no follow-up or resolution was provided. The facility's grievance policy, revised in December 2018, was not followed. The policy requires that grievances be documented and addressed by the grievance official, typically the Administrator or a designee. However, the facility did not complete grievance forms for the residents' concerns, and there was no documentation of investigations or resolutions. Staff interviews revealed that the grievance process was not consistently followed, and the Administrator acknowledged the lack of documentation and resolution. Additionally, the facility did not provide residents with access to grievance forms, preventing them from submitting grievances anonymously. During a facility tour, surveyors found that grievance forms were not available in designated areas, and staff were unaware of their locations. Residents reported not knowing where to find grievance forms and expressed concerns about the facility's lack of follow-up on grievances. The Administrator admitted that the facility did not have a process for residents to submit grievances anonymously, contrary to the facility's policy.
Incomplete MDS Assessments for Cognitive and Pain Evaluation
Penalty
Summary
The facility failed to ensure the completion and accuracy of Section C (Cognitive Patterns) of the Minimum Data Set (MDS) assessments for seven current residents and one discharged resident. These residents, who had various diagnoses including chronic respiratory failure, diabetes mellitus, dementia, quadriplegia, and spinal stenosis, were not properly assessed for their cognitive status. The MDS assessments indicated that the Brief Interview for Mental Status (BIMS) should be conducted, but questions C 0200 through C 0400 were not assessed, resulting in no BIMS score to determine the residents' level of cognition. This oversight was identified during a review of the MDS assessments dated between September and October 2024. Additionally, the facility failed to complete the pain assessment section (Section J) for a discharged resident with spinal stenosis. The MDS assessment indicated that a pain assessment interview should be conducted, but questions J 0300 through J 0600 were left blank, leaving the section incomplete. Interviews with the social worker, MDS nurse, and corporate nurse confirmed that the MDS assessments were incomplete and inaccurate, as Section C was either dashed or marked as not assessed, and the pain assessment was not completed. The staff acknowledged that these sections should have been completed as part of the residents' evaluations.
Insufficient Weekend Staffing in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of residents, particularly on weekends, as evidenced by the Payroll-Based Journal (PBJ) report submitted to CMS for Fiscal Year Quarter 3, 2024. The report highlighted excessively low weekend staffing, triggering a one-star staffing rating. The facility's Healthcare Facility Assessment (FA) indicated a need for 18-21 nurse aides daily based on shift and acuity, but the actual staffing levels on several weekends fell below this requirement. Specific dates were identified where the number of nurse aides was less than the minimum required, impacting the facility's ability to provide timely care. Interviews with residents revealed that call lights were not answered promptly, with delays averaging 45 minutes, indicating insufficient staffing to meet resident needs. Staff interviews corroborated these findings, with nurses reporting frequent call-outs and reliance on agency staff, particularly on weekends. The Scheduling Coordinator acknowledged the issue of call-outs and the use of multiple staffing agencies to cover shifts, yet the facility still struggled to maintain adequate staffing levels. The Director of Nursing (DON) and Consulting Staff confirmed that the facility's staffing ratios were not consistently met, with discrepancies between the FA and actual staffing practices. The DON noted that the A Wing required a higher staffing ratio due to increased acuity, but the facility's staffing did not align with these needs. The lack of a documented staffing policy or minimum standard for hours per patient day (HPPD) further contributed to the deficiency, as the facility relied on census-based staffing without clear guidelines to ensure resident health and safety.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, which could potentially lead to foodborne illness among residents. During a lunch meal service, a dietary aide, referred to as [NAME] #1, was observed handling ready-to-eat food without proper hand hygiene. The aide was seen using the same pair of gloves for multiple tasks, including touching food items, handling a dish rag, and touching her face, without changing gloves or washing hands. This practice was contrary to the guidelines outlined in the 2022 Food Code by the FDA, which mandates that food employees must not contact exposed, ready-to-eat food with their bare hands and should use suitable utensils or single-use gloves, changing them when necessary. Additionally, the facility failed to properly label and date food products in two of the three nourishment kitchenettes. Observations revealed that various food items, including drinks and perishable goods, were stored without resident identification or use-by dates. This included items such as protein drinks, lemon water, and Diet Coke bottles, among others. The facility's policy requires that perishable food brought into the facility must be labeled with the resident's name and use-by date, and nursing staff are responsible for discarding expired items. Interviews with the Food Service Director (FSD) and nursing staff confirmed that the facility's practices did not align with their policies. The FSD acknowledged that gloves should be changed when leaving and returning to the service line and that food products in the kitchenettes should be checked daily for expiration and proper labeling. Despite these policies, the surveyor's observations indicated a lack of compliance, which could compromise the safety and well-being of the residents.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for several residents, leading to discrepancies between the residents' wishes and the documentation in their Electronic Medical Records (EMR). For two residents, the Physician's orders in the EMR did not match the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) forms, which indicated different instructions regarding resuscitation, intubation, and hospital transfer. The Director of Nursing acknowledged that the MOLST and physician's orders should match, but they did not in these cases. Another resident's medical record did not contain a current court-approved treatment plan for the administration of antipsychotic medications, known as a [NAME] Treatment Plan. Although the facility's lawyer eventually provided the current plan, it was not initially present in the resident's medical record, which the Director of Nursing confirmed should have been complete and accurate. Additionally, the facility failed to ensure timely documentation of physician visits for a resident, with a significant gap between documented visits. Furthermore, a resident's Level 2 Pre-admission Screening and Resident Review (PASARR) was not available in the medical record as required, despite being completed and available in the PASARR portal. The Social Worker confirmed that the PASARR should have been part of the medical record to ensure completeness.
Failure to Explain Arbitration Agreements to Residents
Penalty
Summary
The facility failed to properly explain binding arbitration agreements to residents or their responsible parties, resulting in two residents signing these agreements without full understanding. The Administrator, who was responsible for overseeing the arbitration agreement process, was unaware that any residents had signed such agreements. Upon review, it was found that two residents, both with cognitive impairments, had signed arbitration agreements without the agreements being fully explained to them or their healthcare proxies (HCPs). Resident #60, who was admitted with severe cognitive impairment, had an arbitration agreement signed by their HCP. The HCP was not informed about the nature of the arbitration agreement and signed it as part of a stack of documents without any explanation. Similarly, Resident #92, with moderately impaired cognition, signed their own arbitration agreement without understanding its implications. Both residents and their representatives were not made aware of their rights to refuse or rescind the agreement within 30 days. Interviews with nursing staff revealed that they were not adequately informed about the arbitration agreements and did not explain them to residents or their representatives. The nurses admitted to having residents sign the agreements as part of the admission process without providing detailed explanations. The Administrator acknowledged the deficiency in the process and the lack of a policy or procedure for completing arbitration forms, indicating a need for improvement in how these agreements are handled and communicated to residents and their families.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee with the required members attending the meetings. Specifically, the Medical Director did not attend the last two quarterly QAPI meetings, and the laboratory and pharmacy providers did not attend any of the four quarterly meetings throughout the year 2024. The facility's QAPI Program Resource Guide, revised in June 2019, indicated that the QAPI plans should be comprehensive and include all departments and services offered by the facility, with leadership accountable for engaging all members. The facility's QAPI calendar, also revised in June 2019, listed the expected attendees for the quarterly meetings, including the Medical Director, Administrator, Director of Nurses, Lab provider, MDS Nurse, Business office manager, Pharmacy provider, Medical records, and Unit managers. However, the QAPI Attendee sign-in sheets for 2024 showed that neither the Lab provider nor the pharmacy provider attended any of the quarterly meetings, and the Medical Director missed the meetings on July 26 and October 23. During an interview, the Administrator acknowledged that while these members were invited to each meeting, they did not always attend and instead sent in their reports for review. The Administrator was unaware that attendance by certain members was required quarterly.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) for Enhanced Barrier Precautions (EBP) in the care of two residents. Resident #17, who was admitted with diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA), gastrostomy, and quadriplegia, had an EBP sign on the door to their room indicating the need for gown and glove use during high-contact care activities. However, observations revealed that Nurse #9 and Nurse #14 did not adhere to these precautions, with Nurse #9 failing to don a gown during gastrostomy tube care and Nurse #14 not using gloves and a gown while checking the resident's mattress. Similarly, Resident #52, admitted with dementia and MRSA, was also subject to EBP, as indicated by the sign on their door. Despite this, Hospice CNA #1 was observed performing high-contact care activities such as assisting the resident out of bed and providing morning care without wearing the required gown, although gloves were used during some activities. Interviews with the staff involved revealed a lack of awareness regarding the EBP requirements for these residents, indicating a gap in training or communication within the facility. Additionally, the facility did not have a written water management plan or documentation of a facility-specific risk assessment to identify potential growth and spread of Legionella and other waterborne pathogens in the water system. The facility's existing Healthcare Water Management Plan was not specific to the facility and included references to another facility's name and a schematic drawing of a cooling tower not present in the facility. Interviews with the Director of Maintenance and the Administrator confirmed the absence of a facility-specific water management committee, risk assessment, or plan.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that two residents were offered or provided a summary of their baseline care plans within the required timeframe. Resident #60, who was admitted with severe cognitive impairment and had a healthcare proxy activated, did not have a baseline care plan reviewed with them or their responsible party. Interviews revealed that neither the resident nor their healthcare proxy were informed about the goals of the stay, the plan for discharge, or provided with a summary of the care plan. The social worker confirmed that the process for baseline care plans was not followed, as there was no documentation of a 72-hour meeting or evidence that a summary was offered. Similarly, Resident #250, who was alert and oriented, was not provided with a baseline care plan summary or involved in a meeting to discuss their treatment plan. The resident expressed a desire to meet with the facility and their family to discuss their care preferences and goals, but no such meeting occurred. Interviews with staff indicated that the process for initiating and documenting baseline care plans was not adhered to, as there was no evidence of a meeting or summary being offered to the resident.
Failure to Update Resident's Care Plan with Current HCP Status
Penalty
Summary
The facility failed to update the care plan for a resident to reflect the current status of their Health Care Proxy (HCP). The resident, who was admitted with chronic obstructive pulmonary disease and respiratory failure, had their HCP activated for a probable duration of 30 days due to a significant change in their condition. However, the care plan was not revised to indicate that the HCP should have been activated indefinitely, despite changes in the resident's medical orders and admission to hospice care. The deficiency was identified through a review of the resident's medical records and interviews with facility staff. The physician acknowledged forgetting to update the care plan to reflect the indefinite activation of the HCP. The social worker and regional clinical nurse confirmed that the care plan should have been updated to reflect the extended HCP activation, as the resident's HCP had made significant decisions regarding hospice admission and changes to advanced directives without the care plan being updated accordingly.
Deficiencies in Documentation and Care Implementation
Penalty
Summary
The facility failed to adhere to professional standards of practice in the care of three residents, leading to deficiencies in documentation and implementation of care. For one resident with metastatic lung cancer, the Registered Nurse (RN) who pronounced the resident deceased did not document the assessment in the medical record as required. The Director of Nursing (DON), who made the pronouncement, acknowledged the omission during an interview, admitting that he should have documented his assessment, family notification, and the removal of the body by the funeral home. Another resident, who had a stage four pressure injury, did not receive timely implementation of wound care recommendations. The resident's air mattress settings were not adjusted according to the physician's orders for 16 days after the initial recommendation by the Wound MD. Observations revealed that the air mattress was consistently set to 150 lbs., contrary to the prescribed 100 lbs. setting. The Infection Control Nurse confirmed that the orders should have been implemented when the recommendations were made. A third resident, with chronic obstructive pulmonary disease and respiratory failure, was transferred to the hospital without a physician's order. The nursing progress notes indicated the transfers, but the order listing report did not include an order for the transfers on the specified dates. Both a nurse and the DON confirmed the absence of the necessary orders, acknowledging that an order should have been obtained prior to the transfers.
Failure to Implement Safe Smoking Practices for Resident
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident, specifically in relation to smoking practices. The resident, who was admitted with diagnoses including cerebral infarction, depression, and hypertension, was observed smoking in the courtyard without staff supervision and without any protective smoking equipment. The resident's smoking habits were not accurately documented in the Minimum Data Set (MDS) assessment, and the facility's smoking policy was not adhered to, as the resident smoked outside of designated times and without supervision. The resident's initial and quarterly smoking evaluations were incomplete, failing to accurately reflect the resident's smoking status. Despite being cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, the resident's smoking care plan lacked individualized interventions. The resident was also receiving a nicotine patch for smoking cessation, which was not consistent with their occasional smoking behavior when family visited. Interviews with facility staff, including the Activities Director and several nurses, revealed inconsistencies in the implementation of the facility's smoking policy. Staff acknowledged that the resident smoked only with family and that the facility did not provide smoking equipment for the resident. The Director of Nursing confirmed that the smoking evaluations were incomplete and not accurate, and that the resident's care plan should have been individualized to reflect their specific smoking habits. Additionally, the use of a nicotine patch while the resident continued to smoke was identified as an issue that needed to be addressed with the physician.
Failure to Maintain Oxygen Equipment Sanitation
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident, specifically by not maintaining the oxygen equipment in a sanitary manner. The oxygen concentrator for a resident with chronic obstructive pulmonary disease and respiratory failure was observed running without a filter on multiple occasions. This lack of a filter could potentially lead to contamination and infection, as the filter is designed to remove dust, particles, and bacteria from the air intake. The resident, who was cognitively intact and required continuous oxygen therapy, had physician's orders for oxygen at 3 liters per minute via nasal cannula and for oxygen tubing to be changed weekly. Despite these orders, the oxygen concentrator was found without a filter during several observations. Interviews with nursing staff and the Director of Nursing confirmed the absence of the filter, and it was noted that the concentrator model was not one typically used by the facility.
Failure to Develop Trauma-Informed Care Plans
Penalty
Summary
The facility failed to develop a person-centered plan of care that included trauma-informed approaches and identified triggers to avoid potential re-traumatization for two residents with a history of trauma. Resident #39, admitted with diagnoses including depression, psychosis, and anxiety, had a moderate cognitive impairment and reported trauma-related issues. Despite ongoing psychological services, the facility did not identify specific triggers related to the resident's trauma in the care plan. The Social Worker acknowledged that no quarterly assessments had been completed since April 2024, and the care plan was not individualized to the resident's needs. Interviews with staff revealed a lack of awareness regarding the resident's trauma history and triggers. Similarly, Resident #22, admitted with bipolar disorder, anxiety, and depression, was cognitively intact and reported trauma-related issues. The facility's assessments and behavioral health service notes did not identify specific triggers related to the resident's trauma. Interviews with nursing staff indicated a lack of awareness of the resident's trauma history and triggers. The Social Worker confirmed that the care plan was not individualized to the resident's needs, and the Regional Clinical Nurse noted that the care plan was generic and not specific to the resident's trauma and needs. The facility's policy on trauma-informed care, revised in 2019, emphasized the importance of identifying trauma history and triggers to prevent re-traumatization. However, the facility failed to adhere to this policy, as evidenced by the lack of individualized care plans and the absence of identified triggers for both residents. The deficiency highlights the facility's failure to provide trauma-informed and culturally competent care, as required by their policy and regulatory standards.
Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at the required intervals as per regulatory standards and facility policy. Specifically, the resident, who was admitted with diagnoses including cerebral infarct, diabetes mellitus, and hypertension, was not seen by a physician every 30 days for the first 90 days after admission and at least every 60 days thereafter. The medical record indicated a significant gap of 210 days between physician visits, which was not in compliance with the expected schedule of alternating visits between the physician and a nurse practitioner. Interviews with the physician and the Director of Nursing confirmed the oversight. The physician acknowledged that he was late in visiting the resident and should have conducted a visit around 60 days after the previous one. The Director of Nursing reiterated the expectation that residents should be seen in a timely manner, as per the facility's policy and regulatory requirements. This lapse in timely physician visits represents a deficiency in the facility's adherence to required medical oversight for residents.
Failure to Document and Act on Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that the monthly medication regimen reviews (MRR) for two residents were properly documented and included in the medical record. For one resident, the pharmacist completed MRRs over several months, but the recommendations were not available in the medical record or readily accessible for review. The Director of Nursing (DON) confirmed that these reports were kept in a binder in his office and not part of the medical record, which was not in compliance with the facility's policy. Another resident's MRRs for three consecutive months were also not included in the medical record. The pharmacist's recommendations regarding a PRN medication for anxiety/agitation were not acted upon in a timely manner. Although the physician agreed with the recommendations, the necessary updates to the medication order, such as a 14-day stop date and re-evaluation, were not documented in the resident's medical record until the medication was eventually discontinued. Interviews with the DON and other staff revealed that the MRR recommendations were not being integrated into the residents' medical records as required. The DON stated that the recommendations were reviewed with physicians and then filed in a binder, making them inaccessible to unit staff unless specifically requested. This practice was contrary to the facility's policy, which required that such recommendations be documented in the resident's active record and acted upon promptly.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all medications were stored according to accepted professional principles. In one instance, a medication storage room was found to have a clear controlled substance storage box inside a refrigerator that was locked but not permanently affixed to the shelf. This allowed the entire shelf with the box attached to be removed. The box contained a bottle of liquid Ativan, a Schedule IV controlled substance, labeled with a resident's name. Additionally, two cards of Dronabinol capsules, a Schedule III controlled substance, were found resting on a shelf without being stored in a permanently affixed locked box, contrary to the facility's policy. Furthermore, during a medication pass, a nurse left three medication blister packs unattended on top of a medication cart while walking away to the medication room. The medications included Amlodipine, Atorvastatin, and Plavix, and were left unsecured without direct supervision or communication to another nurse to watch them. This was against the facility's policy, which requires medication carts and supplies to be locked when not attended by authorized personnel.
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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