Twin Oaks Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Danvers, Massachusetts.
- Location
- 63 Locust Street, Danvers, Massachusetts 01923
- CMS Provider Number
- 225198
- Inspections on file
- 16
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 47
Citation history
Health deficiencies cited at Twin Oaks Center during CMS and state inspections, most recent first.
The facility failed to ensure staff received required dementia training and did not implement an effective Infection Prevention and Control Program or Antibiotic Stewardship Program. Administrative leadership was unaware of missing training documentation and did not address clinical concerns in QAPI meetings, while the President of Operations was not informed about the lack of QAPI activities. These failures resulted in deficiencies related to staff competency, infection control, and quality assurance.
The facility's governing body did not provide oversight or accountability for the QAPI and infection control/antibiotic stewardship programs, as evidenced by the absence of documentation, lack of program implementation for several months, and unawareness among leadership regarding program status and responsibilities.
The facility did not maintain a comprehensive, data-driven QAPI program for an extended period following a change in ownership, resulting in the absence of key quality initiatives such as Infection Control and Antibiotic Stewardship. Multiple new staff members were hired without required training, registry checks, or health screenings, and there was no evidence of infection monitoring or reporting to the QAPI committee during this time.
The facility did not ensure its QAPI Committee met as required or addressed quality deficiencies, as the program was not implemented for several months following a change in ownership. During this period, there was also no active Infection Control Program, and essential monitoring and data collection activities were not conducted.
The facility did not implement or maintain an infection prevention and control program, failing to track, monitor, or document infections and outbreaks among residents and staff. Despite multiple antibiotic prescriptions for various infections, there was no evidence of surveillance activities, line listings, or reporting data. The DON, IP, and Administrator were unaware of infection rates or trends, and the Medical Director confirmed the absence of an infection control program.
The facility did not implement or document an Antibiotic Stewardship Program, failing to track, monitor, or review antibiotic use for residents over an extended period. Leadership, including the DON, Infection Preventionist, Administrator, and Medical Director, confirmed the absence of infection surveillance, data collection, and program activities as required by facility policy.
Surveyors found that a medication cart was left unlocked and unattended, allowing unauthorized access to medications. Medications on a cart were not properly labeled or dated when opened, and a medication refrigerator lacked a working thermometer and complete temperature logs, resulting in improper storage conditions for temperature-sensitive drugs. Nursing staff and leadership confirmed these practices did not meet facility policy or manufacturer guidelines.
Staff on one unit failed to provide a dignified dining experience by referring to a resident as a 'feeder' instead of using their name. Both a CNA and a nurse used this term in the dining room, and neither was corrected at the time. Facility policy requires residents to be addressed by name, and leadership confirmed that referring to residents as 'feeders' is not acceptable.
The facility did not timely report two separate incidents involving a resident who suffered a head laceration requiring staples and a right femoral neck fracture requiring surgery. Both events were not reported to the state agency as required by facility policy and regulations, with one incident not reported at all and the other reported ten days late. Interviews with the DON and Administrator confirmed awareness of the incidents and the reporting failures.
A resident with schizophrenia, intellectual disability, and PTSD, who exhibited chronic paranoia and delusions, did not have these behavioral health needs addressed in their care plan. Despite documentation and staff awareness of the resident's specific fears and behaviors, the care plan lacked person-centered interventions as required by facility policy.
Two residents did not receive care in accordance with physician orders: one was administered oxygen without a documented order specifying flow rate or tubing change frequency, and another received enteral feeding with the wrong formula and rate. Nursing staff and leadership confirmed the lack of required orders and failure to follow prescribed instructions.
A resident with peripheral vascular disease and cognitive impairment was observed with a soiled, partially exposed wound dressing on the right ankle that had not been changed for three days, despite physician orders and nursing documentation indicating daily changes. Nursing staff and the DON confirmed that daily dressing changes were expected, but direct observation revealed the deficiency.
A resident with severe cognitive impairment and a contracture in the left hand did not consistently receive a physician-ordered rolled washcloth to the contracted hand every shift. Despite documentation indicating the intervention was completed, multiple observations found the facecloth was not in place, and staff could not provide a documented reason for the omission.
A resident with moderate cognitive impairment and multiple diagnoses experienced significant unmonitored weight loss over several months. Facility staff failed to consistently document weights, perform reweighs, or notify the physician and dietitian as required. Dietary interventions were inconsistently applied, and staff interviews revealed a lack of awareness and follow-up regarding the resident's nutritional status.
Two residents with PTSD and significant trauma histories did not have person-centered care plans addressing their trauma, triggers, or history of suicide attempt. Despite documented histories of abuse, violence, and psychiatric diagnoses, the facility's assessments and care plans failed to identify or address these needs, as confirmed by staff interviews.
A nurse administered medications incorrectly to a resident by giving Lactase tablets after a meal instead of before, and by delivering two sprays of saline nasal solution per nostril instead of the ordered one spray. These actions resulted in a medication error rate of 6.06%, exceeding the regulatory limit of 5%.
A resident with impaired cognition and a history of peripheral vascular disease was repeatedly observed with a soiled, unchanged dressing on an open ankle wound, despite nursing documentation in the MAR indicating daily dressing changes. Nursing staff confirmed the dressing had not been changed as recorded, and the DON could not provide a policy on accurate documentation.
A resident was not offered the Influenza vaccine during influenza season, contrary to facility policy. Record review and staff interviews revealed that vaccination tracking was not being performed, and there was confusion among the DON, Infection Preventionist, and Administrator regarding responsibility for the vaccination program.
A resident was not offered the COVID-19 vaccine upon admission or during their stay, as required by facility policy. Record review confirmed the resident remained unvaccinated, and interviews with the DON, Infection Preventionist, Administrator, and Medical Director revealed a lack of tracking and unclear responsibility for the vaccination program.
A resident with cognitive decline and other health issues was hospitalized due to dehydration, acute kidney injury, and hypernatremia after the facility failed to provide adequate hydration. Despite elevated lab results indicating dehydration, the facility did not initiate a hydration protocol or address the lab values promptly, resulting in a delay in treatment.
A resident with severe cognitive impairment and multiple diagnoses had critically high sodium levels that were not promptly communicated to the physician or NP, resulting in a delay in treatment. The resident was eventually sent to the hospital for hypernatremia, dehydration, and acute kidney injury. The Medical Director noted that immediate notification was expected for such critical lab values.
The facility failed to assess hydration status and obtain consent before administering IV hydration to three residents, and did not conduct a required Depakote level test for another resident. Medical records lacked documentation of hydration assessments and consents, and interviews revealed inconsistencies in the consent process.
Deficient Administrative Oversight in Staff Training, Infection Control, and QAPI
Penalty
Summary
The facility failed to provide appropriate administrative oversight to ensure effective use of resources and to attain the highest practicable well-being of each resident. Specifically, the administration did not ensure that pre-employment health requirements and dementia training were provided to all staff, as evidenced by 3 out of 5 new hire employee records lacking proof of dementia training. Additionally, there was a lack of orientation and education for staff on policies and procedures related to dementia care. The administration also failed to implement and maintain an Infection Prevention and Control Program (IPCP), including the absence of an Antibiotic Stewardship Program for monitoring, tracking, and improving antibiotic use and infection control measures. Interviews revealed that the Administrator was unaware of the missing dementia training documentation and could not provide evidence that clinical concerns, such as infection control and antibiotic stewardship, were discussed in QAPI meetings. The Medical Director confirmed the absence of an Infection Control Program and stated that infection monitoring, data collection, and reporting were not in place. Furthermore, the President of Operations was not informed about the lack of QAPI activities for several months and did not review QAPI minutes to ensure compliance. These failures resulted in deficiencies cited under F837, F880, and F881.
Lack of Governing Body Oversight for QAPI and Infection Control Programs
Penalty
Summary
The facility failed to ensure that its governing body provided oversight and accountability for the maintenance of an effective Quality Assurance and Performance Improvement (QAPI) program and the provision of an infection control/antibiotic stewardship program. Review of facility policy indicated that the Administrator is responsible and accountable to the governing body for QAPI implementation, and that QAPI activities should be a standing agenda item for governing body meetings. However, during the survey, the facility was unable to provide documentation related to infection tracking, reporting data, or antibiotic stewardship, and there was no evidence that QAPI had been initiated for these programs. Interviews revealed that the QAPI program had not been implemented from the time of ownership change in June 2024 until February 2025, with no meeting minutes or projects available for that period. The Administrator was unaware that infection control and antibiotic stewardship programs were not being implemented and had not informed the governing body of the lack of QAPI prior to February. Additionally, the President of Operations/owner was not aware of who the governing body representative was for the facility and was not informed about the absence of QAPI activities during the specified period.
Failure to Implement and Maintain Comprehensive QAPI Program
Penalty
Summary
The facility failed to implement and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, as required. Although a QAPI policy was in place, review of records and staff interviews revealed that the program was not operational from June 2024 until February 2025 following a change in ownership. During this period, there were no QAPI meeting minutes or documented projects, and key quality programs such as Infection Control and Antibiotic Stewardship were not being implemented. The Administrator and Director of Nursing both confirmed that these programs were not in place prior to their recent arrival and that the QAPI program had only recently been re-initiated. Further review of new employee records showed multiple deficiencies in staff onboarding and compliance with regulatory requirements. Several new hires lacked required dementia training, CNA registry checks, preemployment physicals, tuberculin testing, and documentation of COVID vaccination or declination. The Director of Nursing's license was not checked prior to employment. The Medical Director also confirmed the absence of an Infection Control Program and stated that infection monitoring, antibiotic stewardship, and vaccination tracking were not being conducted or reported to the QAPI committee. These findings demonstrate a lack of comprehensive, data-driven quality assurance processes and oversight during the identified period.
Failure to Implement and Maintain QAPI Committee and Infection Control Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) Committee met as required and addressed quality deficiencies through the development and implementation of corrective action plans. According to the facility's own QAPI policy, the committee was supposed to meet monthly and include representatives from key departments to monitor, assess, and improve care and operations. However, the Administrator confirmed that the QAPI program was not implemented from June 2024 until February 2025 following a change in ownership, and no QAPI meeting minutes or projects could be found for that period. Additionally, the Medical Director, who began in April 2025, stated that there was no Infection Control Program in place and that infection monitoring, tracking, and data collection were not occurring as expected. The lack of an active QAPI committee and absence of infection control oversight meant that quality gaps, including those related to infection prevention and antibiotic stewardship, were not being systematically identified or addressed during the specified timeframe.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as required, resulting in the absence of a system for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. Despite having a policy that outlines the responsibilities of the Infection Preventionist (IP) and nursing staff for ongoing surveillance, documentation, and reporting of infections, the facility was unable to provide any documented evidence of infection surveillance activities, line listings, or reporting data for an extended period covering several months. During the survey, the facility could not produce records or documentation related to infection tracking or follow-up activities in response to active antibiotic use, even though electronic records showed multiple antibiotic prescriptions for various infections over several months. Interviews with the DON and IP revealed that they were unaware of infection rates, lacked surveillance data, and did not have information on tracking, trending, or outbreak management. The DON stated reliance on verbal reports from nursing staff and admitted to having no data available, while the IP could not provide evidence of an infection prevention program, including antibiotic stewardship or vaccination tracking. Further, the Administrator acknowledged that the infection control program should be implemented and followed but was not aware of the current infection status in the facility, expecting clinical staff to manage these issues. The Medical Director, who started recently, confirmed the absence of an infection control program and stated that monitoring, tracking, and reporting of infections, as well as antibiotic stewardship and vaccination, were not being conducted as expected. No documentation was available to demonstrate compliance with infection prevention and control requirements.
Failure to Implement Antibiotic Stewardship and Infection Control Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program as required by its own policy and regulatory expectations. Record review showed that there was no documentation of tracking, follow-up, or review with the physician or nurse practitioner after antibiotics were prescribed for three active physician antibiotic orders. Additionally, there was no documented information related to antibiotic use or infection surveillance for a period spanning from August 2024 through June 2025. The facility's policy outlined the need for monitoring antibiotic use, staff education, and tracking of related issues, but these actions were not carried out. Interviews with facility leadership, including the DON, Infection Preventionist, Administrator, and Medical Director, confirmed the absence of an active infection control or antibiotic stewardship program. The DON was unable to provide infection rates or data, relying solely on staff reports. The Infection Preventionist could not produce evidence of any infection prevention activities, including line listings, tracking, or surveillance. The Administrator acknowledged that the program should be in place but was not aware of current infection data, and the Medical Director confirmed the lack of an infection control program, stating that monitoring and tracking were not occurring.
Medication Storage, Labeling, and Temperature Control Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications and biologicals. On one nursing unit, a medication cart was observed left unlocked and unattended, allowing access to medications by unauthorized individuals, including residents who were seen walking past the cart. The nurse responsible for the cart was unaware it was unlocked, and both the nurse and the Director of Nursing confirmed that medication carts are required to be locked at all times when not in use. Additionally, medications on one of the medication carts were not labeled or dated according to manufacturer guidelines. Specifically, a bottle of Artificial Tears Lubricant Eye Drops was found open and undated, and the nurse present could not confirm when it had been opened. The Director of Nursing stated that medications should be dated upon opening and that staff are expected to document this information on the bottle. Further deficiencies were found in the storage of medications requiring refrigeration. The medication refrigerator lacked a functioning thermometer, and temperature logs were incomplete, with only 12 out of 30 days documented for one month. The refrigerator was observed to be too warm, with condensation and melting frost present, and medications inside were wet to the touch. The Assistant Director of Nursing acknowledged the refrigerator was not maintaining proper temperature and that there was no record of how long it had been out of range. The Director of Nursing was unaware of the issue and stated that the affected medications would need to be discarded due to unknown temperature exposure.
Failure to Ensure Dignified Dining Experience Due to Inappropriate Resident Labeling
Penalty
Summary
Facility staff failed to ensure a dignified dining experience for residents on the first floor unit by referring to residents as 'feeders' rather than by their names. Observations included a CNA asking a nurse if a resident was a feeder and the nurse responding affirmatively without correcting the terminology. Additionally, a nurse was heard stating, 'We have a feeder left,' while gesturing to a resident at a table. The facility's policy requires staff to address residents by their names of choice and not by care needs or other labels. Both the Assistant Director of Nursing and the Director of Nursing confirmed during interviews that staff should not refer to residents as feeders.
Failure to Timely Report Serious Resident Injuries to State Agency
Penalty
Summary
The facility failed to report two significant incidents involving a resident to the state agency as required by their own policy and regulatory guidelines. The first incident involved a resident with severe cognitive impairment and dependency on staff for activities of daily living, who experienced a fall resulting in a head laceration that required a staple. The fall was unwitnessed, and the resident was found on the floor by staff. After being transferred to the hospital for evaluation and treatment, the resident returned with a staple in the forehead. Despite the seriousness of the injury, there was no evidence that the incident was reported to the state agency. The second incident involved the same resident, who suffered another unwitnessed fall while in a common area, resulting in a displaced fracture of the right femoral neck that required surgical repair. The resident, who does not ambulate independently and uses a wheelchair, was found on the floor and complained of severe pain in the right knee and lower leg, with visible swelling and deformity. Hospital records confirmed the fracture and subsequent surgery. The facility did not report this incident to the state agency until ten days after the fall, which was not in accordance with the required reporting timelines. Interviews with the Director of Nursing and the Administrator confirmed that both were aware of the incidents and acknowledged that the events should have been reported to the state agency as required. The facility's policy mandates immediate reporting of such incidents, especially those resulting in serious bodily injury, but this protocol was not followed in either case.
Failure to Develop Person-Centered Behavior Care Plan for Resident with Paranoia and Delusions
Penalty
Summary
The facility failed to develop a person-centered behavior care plan for a resident with a history of chronic paranoia and delusions. Despite documented evidence in the hospital discharge records and social work notes indicating the resident's diagnoses of schizophrenia, intellectual disability, and post-traumatic stress disorder, as well as specific behavioral concerns such as paranoia around certain staff and delusional beliefs, the care plan did not address these issues. The resident's behaviors included refusing medication from specific staff and expressing fear and distress related to past experiences, which were not reflected in the individualized care plan. Interviews with facility staff, including the Social Worker and Director of Nurses, confirmed that the resident's chronic paranoia and delusions were not included in the care plan, despite facility policy requiring comprehensive assessment and person-centered planning for residents with impaired cognition or mental illness. The omission was identified during a review of the care plan and supporting documentation, which failed to show any interventions or strategies tailored to the resident's behavioral health needs.
Failure to Follow Physician Orders for Oxygen and Enteral Feeding
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for two residents. For one resident with dementia and COPD, the facility did not have a physician's order specifying the amount of oxygen to be administered via nasal cannula, nor instructions on how often the oxygen tubing should be changed. Observations showed the resident consistently using oxygen at 4 liters with unlabeled and undated tubing, and both the ADON and DON confirmed the absence of a required physician's order and related care plan documentation. For another resident with respiratory failure, gastrostomy, tracheostomy, and quadriplegia, the facility did not implement the physician's order for enteral feeding. The resident was observed receiving a different formula and rate (Jevity 1.2 cal at 58 ml/hr) than what was ordered (Jevity 1.5 cal at 55 ml/hr). Nursing staff were unaware of the discrepancy until it was pointed out, and the DON confirmed that physician's orders should be followed as written.
Failure to Provide Timely Wound Dressing Changes
Penalty
Summary
Surveyors found that the facility failed to provide wound care in accordance with physician orders and professional standards for one resident. The resident, who had diagnoses including peripheral vascular disease, anxiety, and depression, was observed with a soiled dressing on the right ankle that was dated three days prior. The dressing was only partially covering the open wound and had visible yellow/brown drainage. Documentation in the Medication Administration Record indicated that nurses had recorded daily dressing changes as ordered, but direct observation by surveyors contradicted these records. Interviews with nursing staff confirmed that the dressing should have been changed daily according to the physician's orders. The Director of Nursing also stated that her expectation was for nurses to follow the physician's orders for dressing changes. The facility's policy on dressings did not specify adherence to physician orders, and the failure to change the dressing as required resulted in the resident having a soiled and exposed wound for at least three days.
Failure to Provide Ordered Range of Motion Care for Resident with Contracture
Penalty
Summary
The facility failed to consistently implement physician-ordered range of motion (ROM) care for a resident with a contracture in the left hand. The resident, who had severe cognitive impairment and functional limitations in both upper and lower extremities, had a physician's order and care plan directing staff to place a rolled washcloth in the contracted left hand every shift to prevent further deterioration. Despite this, multiple observations over consecutive days showed the resident lying in bed without the required facecloth in the left hand. Interviews with staff, including a CNA and a nurse, confirmed that the facecloth was not in place as ordered, and there was no documented rationale in the medical record for this omission. The Treatment Administration Record (TAR) indicated that the intervention was signed off as completed every shift, despite the facecloth not being present during surveyor observations. The Director of Nursing acknowledged that the facecloth should have been in place per the physician's order and that any deviation should have been documented.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately maintain the nutrition and hydration status of a resident by not ensuring that significant weight loss was properly assessed and continually monitored. The resident, who had a history of anxiety, depression, and bipolar disorder and demonstrated moderate cognitive impairment, experienced a substantial decrease in weight over several months. Weight records showed a loss of 26.7% from February to May, with missing weight documentation for March and no evidence of reweighs or physician notification regarding the significant weight loss. Dietary notes indicated the resident triggered for weight loss on multiple occasions, but interventions were inconsistently applied, and the resident sometimes declined supplements. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's weight loss. The nurse was unaware of the significant weight loss and did not know if the physician had been notified, while the Registered Dietitian expected nursing staff to identify and report significant changes. The DON confirmed expectations for monthly weights, reweighs, and notifications but was also unaware of the resident's weight loss and the lack of follow-up. The Medication Administration Reports did not indicate that the resident refused supplements, further highlighting gaps in monitoring and documentation.
Failure to Develop Trauma-Informed Care Plans for Residents with PTSD
Penalty
Summary
The facility failed to develop trauma-informed, person-centered care plans for two residents with documented histories of post-traumatic stress disorder (PTSD) and significant trauma. For one resident with schizophrenia, intellectual disability, and PTSD, the care plan did not identify or address trauma history, triggers, or interventions to minimize re-traumatization, despite hospital records indicating a history of abuse, family violence, and sexual assault. The Trauma Informed Care Assessment for this resident also failed to document any trauma, and both the Social Worker and Director of Nurses acknowledged that a care plan addressing these issues should have been in place. For another resident with anxiety, depression, bipolar disorder, and PTSD, the care plan did not address the resident's PTSD, history of suicide attempt, or identify triggers that could lead to re-traumatization. Medical records from a previous facility documented a suicide attempt and ongoing psychiatric care, but the Trauma Informed Care Assessment did not reflect this history. Staff interviews confirmed that the care plan should have included interventions for PTSD and suicide risk, but these were not present.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required by regulation. During a medication pass observation, one of two nurses made two errors out of 33 opportunities, resulting in a medication error rate of 6.06%. Specifically, a nurse did not follow physician orders for a resident by administering Lactase tablets after the resident had already consumed breakfast, instead of before the meal as ordered. Additionally, the nurse administered two sprays of saline nasal solution in each nostril, rather than the prescribed one spray per nostril. These errors were confirmed through observation, interview, and record review. The nurse acknowledged during an interview that the medications were not administered according to the physician's orders, stating that he should have given the Lactase before the meal and only one spray of saline per nostril. The errors directly impacted one resident who had orders for Lactase for lactose intolerance and saline nasal spray for dryness.
Inaccurate Documentation of Wound Care in Medical Records
Penalty
Summary
Surveyors found that the facility failed to accurately document wound care for one resident with peripheral vascular disease, anxiety, and depression, who had moderately impaired cognition. The resident was observed on multiple occasions with a soiled dressing on the right ankle, dated several days prior, which only partially covered an open wound and showed signs of drainage. Despite this, the Medication Administration Record (MAR) indicated that dressing changes had been documented as completed on three consecutive days. Interviews with nursing staff confirmed that the dressing had not been changed as recorded, and the Director of Nursing acknowledged the expectation for accurate documentation but could not provide a facility policy on the matter. The discrepancy between the observed condition of the dressing and the MAR entries demonstrated a failure to maintain accurate medical records in accordance with professional standards.
Failure to Offer Influenza Vaccine to Resident During Influenza Season
Penalty
Summary
The facility failed to offer the Influenza vaccine to one resident out of a sample of five during the influenza season, as required by facility policy. The policy states that all residents and employees without medical contraindications should be offered the influenza vaccine annually, specifically between October 1st and March 31st. Record review showed that one resident had not been vaccinated for Influenza, and there was no documentation that the vaccine was offered upon admission or during their stay. Interviews revealed a lack of clear responsibility and tracking for the vaccination program. The DON stated she did not track vaccinations and expected the Infection Preventionist to do so, while the Infection Preventionist, new to the facility, was unaware of the vaccination program's status. The Administrator acknowledged the program should be implemented but was not aware of the current vaccination status, and the Medical Director expected vaccination status to be obtained on admission and the vaccine to be offered during influenza season.
Failure to Offer COVID-19 Vaccine to Resident Upon Admission
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to one out of five sampled residents, as required by its own policy and standard infection prevention practices. Record review showed that this resident had not been vaccinated for COVID-19, and there was no documentation that the vaccine had been offered upon admission or during their stay. The facility's policy, revised in January 2023, assigns responsibility to facility leadership and clinical staff to take reasonable measures to protect residents and staff, including offering the COVID-19 vaccine. Interviews revealed a lack of clarity and accountability regarding the vaccination program. The DON stated she does not track vaccinations and expects the Infection Preventionist to do so, while the Infection Preventionist, new to the facility, was unaware of the vaccination program's status. The Administrator acknowledged the program should be implemented but was not aware of the current vaccination status, relying on specialized staff to manage these requirements. The Medical Director, also recently appointed, reported hearing that residents had not been receiving COVID-19 vaccines and expected vaccination status to be obtained on admission and vaccines to be offered if not previously received.
Failure to Maintain Resident Hydration Leads to Hospitalization
Penalty
Summary
The facility failed to maintain the nutrition and hydration status of a resident who required assistance with eating and drinking, leading to hospitalization due to dehydration, acute kidney injury, and hypernatremia. The resident, admitted with conditions including cognitive decline and hypertension, showed a decline in self-feeding ability and required full assistance at meals. Despite recommendations for an occupational therapy evaluation, there was no indication that such an evaluation was conducted. Lab results indicated elevated sodium, chloride, and BUN levels, which were not addressed in a timely manner by the facility staff. The facility's policy on hydration and prevention of dehydration was not followed, as there was no documentation of a hydration protocol being initiated for the resident despite critically high lab values. The nurse practitioner did not address the elevated lab values, and there was a delay in sending the resident to the hospital after receiving notification of critically high sodium levels. The medical director stated that the nurse should have notified the nurse practitioner or physician immediately, considering the delay in treatment a significant issue.
Failure to Notify Physician of Critical Lab Results
Penalty
Summary
The facility failed to promptly notify the physician or nurse practitioner of critically high sodium levels for a resident, leading to a delay in treatment. The resident, who had severe cognitive impairment and required assistance with eating and drinking, was admitted with diagnoses including nontraumatic acute subdural hemorrhage, hypertension, peripheral vascular disease, and cognitive decline. Lab results indicated elevated sodium, chloride, and blood urea nitrogen levels, but there was no documentation that the physician or nurse practitioner was informed of these critical values. The lab company confirmed that a nurse was notified of the critically high labs, but the clinical record did not show that the physician or nurse practitioner was informed. Sixteen hours after the facility was initially notified of the elevated labs, the resident was sent to the hospital due to dangerously high sodium levels. The resident was treated in the hospital for hypernatremia, dehydration, and an acute kidney injury. The Medical Director stated that the nurse should have notified the physician or nurse practitioner immediately, considering this a delay in treatment.
Failure to Assess Hydration and Obtain Consent for IV Hydration
Penalty
Summary
The facility failed to meet professional standards of quality care for four residents by not properly assessing hydration status, obtaining necessary consents, and conducting required lab tests. For three residents, the facility administered intravenous (IV) hydration without assessing their hydration status through lab tests or obtaining consent from their health care proxies or guardians. This lack of assessment and communication was evident in the medical records, which did not document any hydration assessments or consent forms prior to the IV administration. In the case of one resident, the facility did not obtain the required Depakote level as ordered by the physician. Despite the physician's and nurse practitioner's notes indicating the need for a Depakote level check on a specific date, the facility failed to arrange for the lab draw. The Director of Nurses acknowledged that the lab draw could have been scheduled even though it was not the facility's regular lab day. Interviews with the Director of Nursing and the Regional Manager of the IV company revealed a discrepancy in the process of obtaining consent for IV hydration. The Director of Nursing stated that consent is always needed from the health care proxy or guardian before proceeding with IV hydration, while the IV technician expected the facility to have obtained consent prior. This inconsistency contributed to the failure to notify and obtain consent from the responsible parties before administering IV hydration.
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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