St Patrick's Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Framingham, Massachusetts.
- Location
- 863 Central Street, Framingham, Massachusetts 01701
- CMS Provider Number
- 225430
- Inspections on file
- 30
- Latest survey
- March 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at St Patrick's Manor during CMS and state inspections, most recent first.
A resident with multiple health conditions did not receive the prescribed antihypotensive medication, Midodrine, when their SBP was below 100 mmHg, as per physician orders. The facility's MARs for three months showed several instances of low SBP without the administration of the medication, contrary to the facility's medication administration policy. The DON confirmed the oversight during an interview.
A facility failed to accurately execute advance directives for a resident, resulting in a discrepancy between the resident's documented wishes and the care plan. The resident's MOLST form was illegible, and a handwritten card indicating DNR/DNI status was undated and unsigned. Despite this, the care plan indicated a full code status, and no physician's order was obtained. Staff interviews revealed that the resident was presumed a full code due to the unreadable MOLST form, and the necessary review and update of the MOLST form were not completed.
A resident with severe cognitive deficits was found in a stationary chair setup that restricted movement, which was not assessed as a restraint by the facility. The chairs were intended to prevent falls but were positioned in a way that limited the resident's ability to move freely, contrary to the facility's policy. The issue was only recognized after a surveyor's observation.
The facility failed to provide necessary grooming assistance for two residents dependent on staff for ADLs. One resident was observed with unshaved facial hair despite being dependent on staff for grooming, while another had long, untrimmed fingernails with debris, despite care plans indicating the need for short nails. Staff interviews confirmed the residents' dependency on assistance, but grooming was not adequately provided.
A resident with auditory needs was not consistently provided with hearing aids as required, despite physician orders and facility policy. Observations showed the resident without hearing aids during breakfast and interactions, impacting communication. Staff interviews confirmed the expectation for hearing aids to be applied daily, yet this was not consistently done.
A resident receiving enteral feeding due to severe cognitive impairment and malnutrition was found to have unlabeled and undated feeding and water flush bags. The facility's policy requires labeling to prevent misinterpretation, but observations revealed this was not followed. A nurse confirmed the oversight, acknowledging that the bags should have been labeled by the staff responsible for hanging them.
A facility failed to manage a resident's nebulizer equipment according to policy, leaving it unlabeled, undated, and improperly stored. Despite the resident's asthma diagnosis, the nebulizer setup was found exposed and not in a storage bag, contrary to the facility's standards. Interviews confirmed the importance of proper labeling and storage to prevent infection risks.
The facility failed to secure the medication storage room on the Sacred Heart Unit, allowing unauthorized access by the Central Supply Manager (CSM). The CSM was observed inside the room with the door propped open, having used a key provided by a nurse. The room contained prescription medications, emergency kits, and insulin. Facility policy mandates that only Licensed Nurses have access to the medication storage room, which must remain locked at all times.
A facility failed to provide a written notification of transfer or discharge for a resident sent to the hospital due to worsening renal function. The resident, with conditions including ESRD and CKD Stage 4, was transferred without notifying the resident or their representative, and the Ombudsman was not informed. A social worker confirmed the lack of documentation for these notifications.
A resident with End Stage Renal Disease and other conditions was transferred to a hospital without receiving the required Bed Hold Policy Notice. The facility's policy mandates notification upon transfer, but no documentation was found, and a social worker confirmed the notice was not provided.
The facility failed to accurately complete MDS assessments for two residents, leading to incorrect documentation of discharge locations. One resident was recorded as discharged to a hospital but actually returned home, while another was documented as going home but was sent to a hospital. These errors were confirmed by an MDS nurse during interviews.
A resident with a history of hemiplegia and high fall risk was injured during a transfer when a CNA used a Sit/Stand Lift without required assistance. The resident, who needed two staff members for transfers, was lowered to the floor after becoming weak, resulting in a femur fracture and hospital admission.
A resident at high risk of falls, requiring two staff for transfers, was injured when a CNA attempted a transfer alone using a Sit/Stand Lift. The resident slid from the lift, resulting in a femur fracture diagnosed days later. The CNA admitted to not following the facility's policy requiring two staff for transfers.
An incident occurred where a resident, who primarily spoke a language other than English, was verbally abused by a nurse. The nurse yelled at the resident in a humiliating and aggressive manner, insisting they learn English. This behavior was witnessed by other residents and staff, causing the resident to become upset and cry. The nurse also made inappropriate comments about the resident in front of other staff members. The incident was reported by another resident and a nurse who witnessed the actions.
The Facility failed to follow its Abuse Policy when a nurse reported another nurse for verbal abuse. The Nurse Supervisor did not notify the Administrator or DON and did not suspend the accused nurse, who continued to work and care for residents, placing them at risk for further abuse.
Failure to Administer Antihypotensive Medication as Ordered
Penalty
Summary
The facility failed to administer a physician-ordered antihypotensive medication, Midodrine, as needed (PRN) for a resident when their systolic blood pressure (SBP) was documented below 100 mmHg. This deficiency was identified for one resident out of a sample of 36. The facility's policy on medication administration requires reviewing and confirming medication orders and checking vital signs before administering medications. However, the facility did not adhere to this policy, as evidenced by the resident's medication administration records (MARs) for December 2024, January 2025, and February 2025, which showed multiple instances of SBP readings below 100 mmHg without the administration of the prescribed Midodrine. The resident involved was admitted to the facility with multiple diagnoses, including hemiplegia, end-stage renal disease, heart failure, and type 2 diabetes. The resident was cognitively intact, with a perfect score on the Brief Interview for Mental Status. Despite the physician's order for Midodrine to be administered when the resident's SBP was below 100 mmHg, the MARs indicated that the medication was not given on several occasions when the SBP was below the threshold. During an interview, the Director of Nursing acknowledged the oversight and confirmed that the medication should have been administered as ordered.
Failure to Accurately Execute Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were accurately executed for a resident, leading to a deficiency. Upon admission, the resident's MOLST form was illegible, and a handwritten card indicating DNR/DNI status was undated and unsigned. Despite these documents, the resident's care plan inaccurately indicated a full code status, and there was no physician's order for the resident's advance directives. The facility's policy required that advance directives be identified and reviewed upon admission, but this was not done for the resident. Interviews with facility staff revealed that the resident was presumed to be a full code due to the unreadable MOLST form. The Unit Manager acknowledged that the MOLST form should have been reviewed and updated upon admission, and a physician's order should have been obtained. However, these actions were not completed, resulting in a discrepancy between the resident's documented wishes and the care plan, which could lead to inappropriate medical interventions in the event of a change in the resident's condition.
Failure to Assess Stationary Chairs as Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as required by their policy. The resident, who had severe cognitive deficits and required maximum assistance for transfers and ambulation, was observed sitting in a stationary chair positioned in a way that limited their ability to move freely around the room. The stationary chairs were placed in the corner of the room, with one chair on each side of the resident, effectively preventing them from exiting the room. This setup was intended as a safety intervention to prevent falls but was not assessed as a potential restraint, contrary to the facility's policy. The resident's care plans indicated a history of behaviors associated with cognitive decline and a tendency to sit on the floor. Despite these considerations, the facility did not assess the stationary chairs as a restraint when the intervention was initiated. The Director of Nursing acknowledged that the chairs limited the resident's movement and that the interdisciplinary team only assessed the chairs as a restraint after the surveyor's observation. The failure to assess the stationary chairs as a potential restraint led to the deficiency identified by the surveyor.
Failure to Provide Grooming Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary grooming assistance for two residents who were dependent on staff for activities of daily living (ADLs). Resident #164, who was admitted with diagnoses including Hemiplegia, Hemiparesis, and Cognitive Communication Deficit, was observed multiple times with approximately one inch of facial hair on the chin, despite being dependent on staff for personal hygiene and grooming. The resident had not refused care, and a CNA confirmed that the resident had never refused ADL care or facial hair removal. The Director of Nursing stated that it was expected for CNAs to offer and provide facial hair removal with daily care. Resident #556, admitted with diagnoses such as Adult Failure to Thrive, Chronic Kidney Disease Stage 3, and Depression, was observed with long, untrimmed fingernails with debris under and around the nails. The resident required supervision or touching assistance with personal hygiene and had not refused care. The care plan indicated the need to keep fingernails short to prevent skin integrity issues. Despite this, the resident reported that staff had attempted to cut the nails once but were unsuccessful due to inadequate tools, and no further attempts were made. Observations confirmed that the resident's nails remained untrimmed over two days. Interviews with staff, including CNAs and a nurse, revealed that the resident required assistance with all ADLs, and nail care should be part of the routine care provided. However, the CNA responsible had not recently checked the resident's nails, and the nurse acknowledged the need for nail trimming and cleaning. The Director of Nursing also confirmed the expectation for CNAs to perform nail care during morning routines.
Failure to Apply Hearing Aids for Resident
Penalty
Summary
The facility failed to ensure that assistive devices to maintain hearing and enhance communication were utilized for a resident who required staff assistance for insertion and manipulation of hearing aids. The resident, admitted with diagnoses including bilateral glaucoma and auditory hallucinations, had an audiology consult indicating the need for daily assistance with hearing aids. Despite physician orders and treatment administration records indicating that hearing aids should be applied daily during the day shift, observations revealed that the resident frequently did not have the hearing aids inserted during breakfast and other times, impacting their ability to hear and communicate. Multiple observations by the surveyor noted the resident without hearing aids during breakfast and while interacting with staff, despite expressing a desire to hear better. Interviews with nursing staff confirmed that hearing aids should be applied once the resident wakes up and before breakfast, yet the resident was observed without them on several occasions. The medical record did not indicate any refusals by the resident to wear the hearing aids, highlighting a failure in staff adherence to the facility's policy and physician's orders regarding hearing aid placement.
Failure to Label Enteral Feeding Bags
Penalty
Summary
The facility failed to provide necessary care and services related to enteral feeding for a resident, identified as Resident #111, who was admitted with diagnoses including vascular dementia, dysphagia, and moderate protein-calorie malnutrition. The resident was severely cognitively impaired and received nutrition and hydration via a feeding tube. The deficiency was identified when surveyors observed that the enteral feeds and fluids being administered to the resident were not labeled or dated as required by the facility's policy. This policy mandates that all enteral nutrition formula administration containers should be labeled with specific information to avoid misinterpretation and ensure proper care. During observations on two consecutive days, surveyors noted that the bags containing the enteral feed and water flushes were not labeled or dated. Nurse #6, who was responsible for the resident during the 7:00 A.M. to 3:00 P.M. shift, confirmed that the bags should have been labeled and dated by the nursing staff who hung them. The nurse identified the contents of the bags as Jevity product and water for flushes but acknowledged the lack of labeling, which was a deviation from the facility's established procedures for enteral feeding management.
Failure to Properly Manage Nebulizer Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for Resident #246, who was diagnosed with Alzheimer's and Asthma. The deficiency was identified when the nebulizer setup equipment for the resident was found to be unlabeled, undated, and not stored in a storage bag, contrary to the facility's policy. The policy required the night nursing shift to date and label the nebulizer tubing and bag, and store them in a labeled and dated plastic bag after drying. The equipment was also supposed to be changed weekly. However, observations on two separate occasions revealed that the nebulizer tubing and handheld piece were left exposed on a chair cushion and a shelf in the resident's room, without proper labeling or storage. Interviews with Nurse #1 and the Director of Nursing confirmed the importance of bagging the nebulizer equipment to prevent infection control issues and the necessity of labeling and dating the equipment to track when it was last changed. Despite the facility's policy and the physician's orders, the nebulizer equipment for Resident #246 was not managed according to the required standards, leading to a failure in maintaining proper respiratory care and potentially exposing the resident to infection risks.
Unauthorized Access to Medication Storage Room
Penalty
Summary
The facility failed to ensure that medications were stored securely in the Sacred Heart Unit's medication storage room. The Central Supply Manager (CSM) was observed inside the medication storage room with a cart of supplies propping the door open, and no other staff were present in the immediate area. The CSM accessed the room using a key provided by Nurse #2, who was not supervising the CSM at the time. The facility's policy requires that only authorized personnel, specifically Licensed Nurses, have access to the medication storage room, and that the room remains closed and locked at all times. The medication storage room contained prescription medication cards, emergency medication kits with Narcan, anaphylaxis medications, and a refrigerator with insulin. During interviews, both the CSM and Nurse #2 acknowledged that the CSM regularly accessed the medication storage rooms unsupervised to stock over-the-counter medications. The Administrator confirmed that the CSM should not have been given the nursing keys and should not have been in the medication storage room unsupervised, as access is restricted to Licensed Nurses and the Licensed Nurse management team.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide a written notification of transfer or discharge for a resident who was transferred to the hospital. The resident, who had been admitted to the facility with diagnoses including End Stage Renal Disease, Diabetes Mellitus Type 2, and Chronic Kidney Disease Stage 4, was sent to the hospital due to worsening renal function. Despite obtaining a physician's order for the transfer and documenting the transfer in a nurse's note, there was no evidence that a written notice of transfer or discharge was provided to the resident or their representative. Additionally, the facility did not notify the Office of the State Long-Term Care Ombudsman about the resident's transfer to the hospital. During an interview, a social worker confirmed the absence of documentation for the written notice and the notification to the Ombudsman. The social worker acknowledged that the written notice should have been completed at the time of the transfer and included in the notification list sent to the Ombudsman every two weeks.
Failure to Provide Bed Hold Policy Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a Bed Hold Policy Notice to a resident or their representative upon the resident's transfer to a hospital. This deficiency was identified during a review of the facility's records and an interview with a social worker. The facility's policy, effective since December 2018 and reviewed in March 2020, mandates that residents and their representatives be notified of the Bed Hold and Return to Facility Policy upon admission and transfer. This policy ensures that residents are informed about the state's bed hold duration, payment, and their right to return to the facility after hospitalization or therapeutic leave. In the case of the resident involved, who was admitted in June 2022 with diagnoses including End Stage Renal Disease, Diabetes Mellitus Type 2, and Chronic Kidney Disease Stage 4, there was no documentation of the Bed Hold Policy Notice being provided. The resident was transferred to an acute care hospital for evaluation of worsening renal status, as per a physician's order. However, during an interview, the social worker was unable to provide evidence that the required written notice had been given to the resident or their representative at the time of transfer.
Inaccurate MDS Assessments for Discharge Locations
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in the recorded discharge locations. Resident #253, who was admitted with diagnoses including an unspecified fall and Adult Failure to Thrive, was inaccurately documented as being discharged to a Short-Term General Hospital. However, the nursing progress notes and discharge summary indicated that the resident actually returned home on the same day. This error was confirmed during an interview with MDS Nurse #1, who acknowledged that the MDS assessment should have reflected the discharge to home. Similarly, Resident #254, admitted with Alzheimer's Disease and age-related osteoporosis, was incorrectly recorded as being discharged to their home in the community. In contrast, the SBAR communication form and nursing progress notes revealed that the resident was transferred to a hospital for further evaluation. MDS Nurse #1 confirmed the inaccuracy during an interview, stating that the MDS assessment should have been modified to reflect the hospital discharge. These inaccuracies in the MDS assessments highlight a failure in ensuring accurate documentation of discharge locations for residents.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff consistently implemented and followed interventions identified in a resident's care plan. A resident, who required extensive assistance from two staff members during transfers for safety, was transferred by a CNA using a Sit/Stand Lift device without the assistance of another staff member. During the transfer, the resident became weak, started to slide out of the lift seat, and was lowered to the floor by the CNA. The resident complained of pain and was later diagnosed with a right femur fracture, requiring hospital admission for treatment. The resident had a history of hemiplegia and hemiparesis following a stroke, difficulty walking, lack of coordination, unsteadiness on feet, and anemia in the setting of chronic kidney disease. The resident was assessed as being at high risk for falls and required maximum assistance from staff with transfers and mobility. The care plan and CNA Care Kardex indicated that the resident required extensive assistance from two staff members for all transfers, which was not followed by the CNA involved in the incident. The CNA admitted to not reviewing the resident's CNA Care Kardex on the day of the incident and had previously transferred the resident without assistance, believing the resident was strong enough to participate. However, this was contrary to the care plan requirements. The CNA also claimed the resident had socks and shoes on during the transfer, which conflicted with the nurse's observation that the resident did not have socks or shoes on when found on the floor.
Removal Plan
- Resident #1 fell, was assessed by Nursing for any injuries, and was transferred to the Hospital Emergency Department for evaluation.
- Resident #1's Care Plan was reviewed and updated to include the fall and to ensure transfer status indicated he/she required physical assistance of two staff for all transfers.
- Resident #1 returned to the facility, nursing reviewed the Hospital ED Discharge Summary which indicated no fractures found, but continued pain led to an X-ray revealing a right femur fracture.
- Resident #1's Care Plan was updated to include the fracture and that he/she required extensive assistance from two staff members using a Hoyer Lift.
- The Interdisciplinary Team reviewed Resident #1's fall, X-ray results, and need for hospital transfer, and continues to update the Plan of Care.
- The Facility Nursing Staff completed an Audit to ensure all residents using mechanical devices had appropriate Care Plans and CNA Care Kardex instructions.
- Mandatory education for all Licensed Nurses and CNAs was initiated, including competencies on Sit/Stand Lift device and review of residents' care plans.
- All Sit/Stand Lift devices were inspected by the Maintenance Department to ensure safety.
- Physical Therapy Department Staff completed Audits to ensure transfer status and staff assistance needs were up to date on residents' Plan of Care and CNA Care Kardex.
- Random Audits were completed by administrative staff on Resident transfers with the Sit/Stand Lift to ensure procedures are followed.
- Audit results were presented at Quality Assurance Performance Improvement meetings, with ongoing review until 100% staff compliance is met.
- The facility's QAPI meeting minutes indicated a plan to continue reviewing concern areas for potential deficient practice, including falls.
- The Director of Nurses and/or designee are responsible for overall compliance.
Inadequate Supervision During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident who was at high risk of falls, resulting in a serious injury. The resident, who had a history of hemiplegia and hemiparesis following a stroke, required the assistance of two staff members for transfers. However, on the day of the incident, a CNA attempted to transfer the resident using a Sit/Stand Lift device without the required assistance of another staff member. During the transfer, the resident began to slide out of the lift seat, and the CNA attempted to lower the resident to the floor, resulting in the resident complaining of hip pain. The resident was initially assessed at the hospital emergency department, where no fractures were found. However, the resident continued to experience pain, and an X-ray conducted at the facility several days later revealed a distal right femur fracture. The fracture was attributed to the forceful movement during the fall, which occurred when the resident was being transferred without the necessary assistance. Interviews with the CNA and other staff members revealed inconsistencies in the account of the incident. The CNA admitted to not using a gait belt or having another staff member assist during the transfer, contradicting earlier statements made to the Physician Assistant, Director of Nursing, and Administrator. The facility's policy required two staff members for such transfers, and the failure to adhere to this policy directly contributed to the resident's injury.
Removal Plan
- Resident #1 fell, was immediately assessed by Nursing for any injuries, Resident #1 had reported he/she had pain to right hip, and was transferred to the Hospital Emergency Department (ED) for evaluation.
- Resident #1's Care Plan was reviewed and updated to include the fall, and to ensure transfer status indicated he/she required physical assistance of two staff for all transfers.
- Resident #1 returned to the facility, nursing reviewed the Hospital ED Discharge Summary (Final Report) which indicated Resident #1 was assessed and treated at the ED with no fractures found. However, he/she continued to experience pain and an X-ray completed at the facility a few days later indicated he/she had a right femur fracture.
- Resident #1's Care Plan was updated to include that Resident #1 was in pain, Facility X-ray indicated Resident #1's right femur was fracture status post fall, which was not previously diagnosed, that he/she had been transferred back to the ED and was admitted to the Hospital.
- The Facility's Morning Meeting and the Weekly Risk Meeting Fall Review minutes indicated the Interdisciplinary Team (IDT) reviewed Resident #1's fall, his/her X-ray results, and need for him/her to be transferred back to the Hospital ED for evaluation. The minutes indicated the IDT continues to discuss (and update as needed) Resident #1's Plan of Care including orthopedic appointments, weight bearing status, nutritional status, and overall health status.
- The Facility Nursing Staff completed an Audit to ensure all residents who used any type of mechanical device, that their individual Care Plan and the CNA Care Kardex indicated the appropriate type of device to be used and how many staff were needed for assistance with the transfer.
- The Staff Development Coordinator (SDC) and the DON initiated mandatory education for all Licensed Nurses and CNA's, which included completion of competencies on Sit/Stand Lift device, and staff were required to complete return demonstration of appropriate use of the transfer device. Education also included nursing staff requirement to review and follow residents plan of care, knowledge of how to access and review the CNA Care Kardex, prior to providing care.
- Resident #1's Care Plan was updated to include, right distal femur fracture related to a fall, and that he/she required extensive assistance from two staff members using a Hoyer Lift (mechanical lift used to safely transfer patients).
- All Sit/Stand Lift devices were Inspected by the Maintenance Department, to ensure all parts were functioning properly and transfer device was safe to use.
- Physical Therapy Department Staff also initiated and completed Audits related to the incident to ensure all residents including new admissions, that their transfer status degree and number of staff needed for assistance during the provision of all care need areas identified were up to date on residents Plan of Care and CNA Care Kardex.
- Random Audits were completed by administrative staff, on Resident transfers with the Sit/Stand Lift to ensure that transfer procedures from Sit/Stand Lift Competencies are being followed by staff. Random Audits will be completed by the DON three times weekly for 3 months.
- The DON presented the Audit results at monthly Quality Assurance Performance Improvement (QAPI) meeting, where the QAPI Committee discussed the results. The DON will present the Audit results for three months, then quarterly until the Committee determines 100% staff compliance is met, and the concern area thereafter will be present for yearly review.
- Review of the facility's most recent QAPI meeting minutes indicated leadership's plan is to continue to review the concern areas for potential deficient practice, including falls, to ensure that residents were provided with appropriate level of assistance as determined by assessments and identified in the residents Plan of Care and CNA Care Kardex.
- The Director of Nurses (DON) and/or designee are responsible for overall compliance.
Verbal Abuse Incident Involving Non-English Speaking Resident
Penalty
Summary
The report details an incident at a long-term care facility where a resident, identified as Resident #2, who primarily spoke a language other than English, was subjected to verbal abuse by Nurse #1. On April 8, 2024, during the evening shift, Nurse #1 yelled at Resident #2 in a humiliating and verbally aggressive manner, telling Resident #2 that he/she needed to learn English as they were now in America. This incident was witnessed by other residents, causing Resident #2 to become upset and cry. Resident #2 had a medical history that included diagnoses of Parkinson's disease, type 2 diabetes mellitus, major depressive disorder, sleep terrors, spinal stenosis, and hypertension. The facility's investigation revealed that Nurse #1 not only verbally abused Resident #2 but also made inappropriate comments about the resident in the presence of other staff members. Nurse #1's behavior was reported by Resident #1, who heard the verbal abuse, and by Nurse #2, who witnessed Nurse #1's actions and reported them to the Nurse Supervisor. Additionally, Certified Nurse Aide (CNA) #3 and Resident #3 corroborated the incident, stating that Nurse #1 had aggressively yelled at Resident #2 in a humiliating manner, causing Resident #2 to appear scared and upset. The Administrator of the facility took immediate action upon receiving reports of the incident, including suspending and ultimately terminating Nurse #1, who was a contracted staff member from an agency. Despite attempts to interview Nurse #1 for the investigation, she did not respond to requests. The facility's policies on abuse prevention and resident rights were cited in the report, emphasizing the importance of providing a safe and respectful environment for all residents, regardless of their language or background.
Failure to Follow Abuse Policy
Penalty
Summary
The Facility failed to ensure staff implemented and followed their Abuse Policy when an allegation of verbal abuse was reported. On the evening shift, a nurse reported that another nurse had been verbally abusive towards a resident. The Nurse Supervisor did not immediately notify the Administrator and Director of Nursing (DON) of the alleged abuse and did not suspend the accused nurse. As a result, the accused nurse continued to work the overnight shift, providing care to the resident and other residents, placing them at risk for potential further abuse. The Facility's Internal Investigation revealed that the management team did not become aware of the incident until three days later when the Administrator received an email from a family member. The investigation included statements from witnesses and confirmed that the accused nurse had been verbally abusive. Despite the Facility's Abuse Policy requiring immediate action, the Nurse Supervisor failed to follow the protocol, resulting in the accused nurse continuing to work and interact with residents during the investigation period.
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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