Willow Brook Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Massachusetts.
- Location
- 90 West Street, Wilmington, Massachusetts 01887
- CMS Provider Number
- 225568
- Inspections on file
- 19
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Willow Brook Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses required two-person assistance for transfers, as per their care plan. However, a CNA transferred the resident alone, resulting in injuries. The facility's investigation confirmed the CNA did not follow the care plan, leading to the deficiency.
The facility failed to maintain professional standards in urinary catheter care for four residents. One resident's drainage bag was not emptied as ordered, another's bag was found on the floor, a third's bag was not emptied and had the wrong catheter size, and a fourth's bag was directly touching the floor. These actions were contrary to the facility's policy, which required regular emptying and keeping the bag off the floor.
The facility failed to follow professional standards for medication storage and handling, with medications not dated upon opening, leading to expired drugs being used. Medications were prepared in advance and stored improperly, and medication carts were left unlocked and unattended, allowing unauthorized access. The DON confirmed that medications should be dated and discarded according to guidelines, and carts should remain locked when unattended.
The facility failed to comply with food safety standards by not labeling and dating food in unit kitchenette refrigerators and improperly handling dented cans. Observations included undated water bottles, food containers, and juice pitchers, as well as dented cans on the can rack. Staff interviews confirmed these practices were against facility policy.
Two residents in the facility were observed without privacy bags for their urinary catheter drainage bags, despite expressing interest in having them. Both residents were cognitively intact and had no documented refusal of care. Staff interviews confirmed that privacy bags should always be used to prevent urine visibility.
A facility failed to assess a resident's ability to self-administer medication, as required by policy. The resident, with diabetes and hyperlipidemia, self-administered a Trulicity injection without documented assessment or consent. Despite being cognitively intact, the facility did not evaluate the resident's mental and physical abilities or obtain consent, as confirmed by the ADON.
A facility failed to implement a comprehensive care plan for a resident, neglecting weekly weight monitoring and not addressing the resident's history of suicide attempts. The resident, with conditions including CHF and depression, experienced a significant weight gain due to missed weekly weigh-ins. Staff interviews revealed an expectation for weekly weights, which were not documented, and a lack of awareness of the resident's suicide attempt history, indicating a failure in care planning.
The facility failed to follow physician orders for a resident's wound care and delayed arranging a necessary urology follow-up for another resident. A resident with skin grafts did not receive the prescribed triple-antibiotic cream during a dressing change, and another resident's urology appointment was not scheduled until five months after hospital discharge.
A resident with cognitive impairment and multiple diagnoses was observed with an undated, saturated dressing on a skin tear, which lacked physician treatment orders. Despite a progress note indicating the wound was resolved, the wound remained open with drainage. Interviews confirmed that treatment orders should have been maintained.
A resident with anoxic brain damage and a stage two pressure ulcer on the left hip did not have a documented physician's order for wound care. Despite the wound physician's recommendations, the treatment was not recorded in the resident's Treatment Administration Record. Nurse #5 provided care based on the wound physician's advice without a confirmed order, and the Director of Nursing acknowledged the lapse in obtaining and documenting the necessary physician's order.
A resident with severe cognitive impairment and a history of falls was not provided with adequate fall prevention measures. Despite a care plan intervention to keep the resident's walker within reach, observations revealed the walker was consistently out of reach. Staff interviews confirmed awareness of the resident's fall risk and the expectation to implement care plan interventions.
A resident with malnutrition and chronic kidney disease experienced significant weight loss after refusing tube feeding. The dietitian recommended increasing a nutritional supplement, Nepro, to three times a day, which was approved by the physician. However, the order was not entered, and the resident did not receive the increased supplement frequency, as confirmed by the dietitian and DON.
A resident with heart failure and hypertension did not receive proper care for a peripheral IV catheter. The facility failed to flush the catheter and monitor the IV site for complications, as required by their policy. The necessary physician's orders for these actions were not documented, leading to a deficiency in care.
A resident with COPD and dependent on oxygen was found with a dirty oxygen concentrator filter, contrary to the facility's policy and physician's orders. The resident was cognitively intact and being weaned off oxygen. The facility's policy required weekly cleaning of the filter, which was not adhered to, as confirmed by staff interviews.
The facility failed to ensure proper dialysis care for residents, including obtaining physician orders and documenting post-dialysis weights. A resident lacked active orders for dialysis treatment, while two others had inconsistent weight documentation. Interviews revealed staff were unaware of these deficiencies, and discrepancies were found in weight records.
A resident received incorrect medications due to errors by a nurse, resulting in a medication error rate of 6.25%. The nurse administered the wrong form of aspirin and an incorrect dose of calcium plus vitamin D3, contrary to the physician's orders. The facility's policy requires correct medication administration by verifying the physician's order and medication label.
A facility failed to implement its infection prevention and control program during wound care. Observations showed that a nurse and a CNA did not perform hand hygiene after removing gloves while treating a resident with leg wounds. Despite handling soiled dressings and using an electronic tablet, they repeatedly changed gloves without washing or sanitizing their hands. Interviews confirmed the oversight, with staff acknowledging the lapse and the DON affirming the need for hand hygiene between glove changes.
The facility failed to transmit MDS discharge assessments to CMS within the required timeframe for two residents. Despite completion, the assessments were not transmitted, as confirmed by the DON and an MDS Nurse, leading to non-compliance with CMS guidelines.
A resident was inaccurately coded as comatose in the MDS, leading to a failure in assessing key areas such as hearing and cognitive patterns. Observations and staff interviews revealed the resident was communicative and interactive, contradicting the MDS coding. The DON confirmed the resident's improved condition and the need for accurate MDS representation.
Failure to Follow Care Plan for Resident Transfers
Penalty
Summary
The facility failed to ensure that staff consistently implemented and followed the interventions outlined in the care plan for a resident who required assistance from two staff members for transfers. On a specific evening shift, a Certified Nurse Aide (CNA) transferred the resident back to bed by physically lifting them from their wheelchair without the assistance of another staff member, contrary to the care plan's requirements. This action was inconsistent with the facility's policy for a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's needs. The resident involved was admitted to the facility in October 2020 with diagnoses including Alzheimer's, Failure to Thrive, Atrial Fibrillation, and Aphasia. The resident was severely cognitively impaired and dependent on staff for various activities of daily living, including transfers. The incident led to the resident sustaining a bump above the left eye, bruising, and shoulder redness of unknown origin. The facility's investigation revealed that the CNA did not review the resident's care card and performed the transfer alone, which was against the care plan's directive for two-person assistance.
Deficiencies in Urinary Catheter Care
Penalty
Summary
The facility failed to maintain professional standards in the management and care of urinary catheter devices for four residents. For one resident, the facility did not empty the urinary drainage bag as ordered, resulting in the bag containing 1200 milliliters of urine. The resident, who was cognitively intact, reported that staff did not empty the drainage bag frequently. The facility's policy required the drainage bag to be emptied every eight hours or more often if needed, but this was not adhered to. Another resident, who was moderately cognitively impaired, was observed with a urinary drainage bag lying on the floor and containing 600 milliliters of bloody urine. The facility's policy required the drainage bag to be kept off the floor to prevent contamination and damage. Despite this, the resident's drainage bag was not maintained according to the policy, and the resident was being followed by urology for ongoing hematuria. A third resident, who was cognitively intact, had a urinary drainage bag that was not emptied as ordered, with the bag containing up to 1200 milliliters of urine at times. The resident reported that staff did not empty the catheter, and sometimes a family member would do it. Additionally, the catheter size did not match the physician's orders. Lastly, another resident's urinary catheter drainage bag was observed directly touching the floor without a barrier, contrary to the facility's policy. This resident was physically unable to manage the drainage bag due to dexterity issues, and staff failed to ensure the bag was kept off the floor.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to adhere to accepted professional standards for medication storage and handling, as observed during a survey. Medications were not dated upon opening, leading to expired drugs being used beyond their recommended disposal dates. Specifically, a fluticasone propionate and salmeterol inhaler was used 55 days after opening, exceeding the 30-day guideline. Similarly, a vial of Lantus insulin and atropine drops were undated, despite needing disposal 28 days post-opening. Additionally, medications were prepared in advance and stored improperly, with crushed medications labeled with resident names but not sealed, and an unknown pill stored in an incorrect container. The facility also failed to secure medication carts properly. On multiple occasions, medication carts were left unlocked and unattended in the hallway, allowing unauthorized access. This was observed on the Andover Unit, where nurses admitted to leaving carts unlocked when out of sight. Furthermore, unauthorized personnel accessed medication carts, as seen when the Assistant Director of Nursing (ADON) used a cart without completing the necessary narcotic count or signing out the cart, which is against facility policy. These deficiencies highlight lapses in medication management and security protocols within the facility. The Director of Nursing (DON) confirmed that medications should be dated and discarded according to guidelines, and carts should remain locked when unattended. The DON also stated that only authorized nurses who have completed the narcotic count should access medication carts, emphasizing the importance of adhering to established procedures to ensure resident safety and compliance with professional standards.
Food Safety and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed by surveyors. Specifically, the facility did not ensure that food items in the unit kitchenette refrigerators were properly labeled and dated. Observations included undated and unlabeled water bottles filled with a green liquid, a white plastic bag containing undated food containers, and several undated plastic pitchers of various juices. Additionally, two undated containers of resident food were found in another unit's kitchenette refrigerator. These findings indicate a lack of compliance with the facility's policy, which requires all food to be dated and discarded after three days. Furthermore, the facility did not properly handle dented cans, which pose a risk for botulism. A significantly dented can of pumpkin and a dented can of mandarin oranges were found on the can rack in the kitchen, contrary to the facility's policy that dented cans should be set aside in a separate labeled area to avoid use. Interviews with the cook and the Food Service Director confirmed that dented cans should not be placed on the can rack and should be returned to the vendor. These deficiencies highlight lapses in food safety practices and adherence to established policies within the facility.
Failure to Provide Privacy Bags for Urinary Catheter Drainage
Penalty
Summary
The facility failed to maintain a dignified existence for two residents by not providing privacy bags for their urinary catheter drainage bags. Resident #471, who was admitted with diagnoses including benign prostatic hyperplasia, brain cancer, and hemiplegia, was observed multiple times without a privacy bag on their urinary catheter drainage bag. The resident expressed interest in having a privacy cover, but it was not provided. The facility's policy and the resident's care plan did not indicate any refusal of care or privacy bag, and staff interviews confirmed that privacy bags should always be used. Similarly, Resident #117, admitted with Parkinson's disease and benign prostatic hyperplasia, was also observed without a privacy bag on their urinary catheter drainage bag. The resident, who was cognitively intact, stated that staff did not offer a privacy cover, although they would be interested in having one. The resident's care plan did not document any refusal of a privacy bag, and staff interviews reiterated the expectation that urinary catheter drainage bags should have privacy covers to prevent urine from being visible to others.
Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the interdisciplinary team was involved in determining whether the self-administration of medications was clinically appropriate for a resident. Specifically, the facility did not assess if it was clinically appropriate for a resident to self-administer an injection prior to the resident doing so. The facility's policy requires that criteria be met to determine if a resident is both mentally and physically capable of self-administering medication, and that staff and practitioners assess each resident's abilities. However, there was no record of such an assessment for the resident in question. The resident, who was admitted with diagnoses including diabetes and hyperlipidemia, was observed self-administering a Trulicity injection without any documented assessment of their mental and physical abilities or a completed consent for self-administration. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. Despite this, the facility's records did not reflect any evaluation or consent process, and the Assistant Director of Nursing confirmed that these steps should have been completed but were not.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically neglecting to implement weekly weight monitoring as care planned and to develop a care plan for the resident's history of suicide attempts. The resident, who was admitted with diagnoses including heart failure, renal insufficiency, anxiety disorder, depression, and PTSD, had a care plan that required weekly weight checks due to risks associated with CHF and hypertension. However, the facility did not obtain weekly weights for several weeks, resulting in a significant weight gain of 39.4 lbs, which was 26.2% of the resident's total body weight in one month. Interviews with facility staff, including a nurse, registered dietitian, nurse practitioner, and the director of nursing, revealed that the expectation was for residents at risk for fluid retention to be weighed weekly. The failure to adhere to this care plan was acknowledged by the staff, who indicated that weights should be recorded in the electronic health record according to the care plan's frequency. The resident's medical record did not indicate any refusal to be weighed, and the oversight led to the resident being placed on diuretic therapy due to increased edema. Additionally, the facility did not develop a care plan addressing the resident's history of suicide attempts, despite the resident having a documented history of severe depression and two suicide attempts. Interviews with the nurse and social worker assigned to the resident revealed that they were unaware of the resident's history of suicide attempts and expected a care plan to be in place to address this issue. The director of nursing also confirmed that a care plan should have been developed for the resident's history of suicide attempts.
Failure to Implement Physician Orders and Arrange Follow-Up Care
Penalty
Summary
The facility failed to provide services that met professional standards of quality for two residents. For Resident #473, who was admitted with diagnoses including diabetes and soft tissue disorder, the facility did not implement the physician-ordered treatment for skin graft wounds. The physician's order specified cleansing the wounds with soap and water, applying triple-antibiotic cream, and covering with xeroform. However, during a dressing change, Nurse #2 used normal saline instead of soap and water and omitted the triple-antibiotic cream. This deviation from the prescribed treatment was acknowledged by both Nurse #2 and the Director of Nursing (DON). For Resident #14, who was admitted with neuromuscular dysfunction of the bladder and other conditions, the facility failed to arrange a follow-up urology appointment after a hospital discharge in March 2024. The discharge paperwork indicated the need for outpatient follow-up with urology for management of neurogenic bladder and chronic Foley catheter. The clinical record did not show any evidence of an arranged appointment until five months later, when the DON confirmed an appointment had been made. This delay in arranging necessary follow-up care was identified during the survey.
Failure to Maintain Treatment Orders for Skin Tear
Penalty
Summary
The facility failed to provide quality care according to physician orders and professional standards for a resident with a skin tear. The resident, who was moderately cognitively impaired and had diagnoses including muscle wasting and end-stage renal disease, was observed with a saturated, undated dressing on their left elbow. The resident reported acquiring the skin tear during transportation from an outside hospital. Upon further observation, the dressing was found to be undated and covering a xeroform gauze with bloody drainage, indicating the wound was still open. A review of the medical record revealed no treatment orders were in place for the skin tear, despite a nurse progress note indicating that the wound doctor had resolved the issue and discontinued dressing orders. The care plan, however, included interventions to apply treatment as ordered by a physician and to position the left arm on a pillow. Interviews with Nurse #3 and the Assistant Director of Nursing confirmed that treatment orders should have been maintained, as the wound was still open and required dressing treatments with physician orders.
Failure to Document Physician's Order for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide necessary treatment to promote the healing of a pressure ulcer for Resident #39. Resident #39, who was admitted with anoxic brain damage and was at risk for pressure ulcers, had a stage two pressure ulcer on the left hip. Despite the wound physician's evaluations and recommendations for treatment, there was no physician's order for the wound care documented in the resident's records. The Treatment Administration Record from 9/1/24 to 9/19/24 did not include any treatment for the pressure ulcer, indicating a lack of formal documentation and physician authorization for the care being provided. Observations and interviews revealed that Nurse #5 was performing wound care based on the wound physician's recommendations without a confirmed physician's order. The Director of Nursing acknowledged that recommendations from the wound physician should be confirmed with the attending physician and transcribed into the electronic health record as an official order. This oversight in obtaining and documenting a physician's order for the pressure ulcer treatment led to the deficiency identified by the surveyors.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident with severe cognitive impairment, who had a history of multiple falls. The resident, admitted with diagnoses of cancer and malnutrition, scored a 5 out of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Despite the resident's history of falls while attempting to self-transfer, the facility did not implement the care plan intervention of keeping the resident's walker within reach while in bed. This intervention was initiated on April 30, 2024, but was not observed to be in place during multiple observations by the surveyor on September 18 and 19, 2024. Interviews with facility staff, including a CNA, two nurses, and the Director of Nursing, confirmed that the resident was at risk for falls and had a history of falling while attempting to self-transfer. The staff members acknowledged that they would expect the care plan interventions for fall prevention to be implemented. However, during the surveyor's observations, the resident's walker was consistently found folded and out of reach, indicating a failure to adhere to the prescribed fall prevention measures.
Failure to Implement Dietitian's Nutritional Recommendations
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident diagnosed with protein calorie malnutrition, diabetes, and chronic kidney disease. The resident, who was cognitively intact, experienced significant weight loss and was receiving more than half of their calories through tube feeding. However, the resident began eating by mouth and refused tube feeding. The dietitian recommended increasing the frequency of a nutritional supplement, Nepro, to three times a day, which was approved by the physician. Despite this, the order was not entered, and the resident's medication administration record did not reflect the increased frequency. The dietitian acknowledged forgetting to input the physician's order for the increased supplement frequency. The Director of Nursing confirmed that the dietitian was responsible for entering the physician's order, which was not done. This oversight resulted in the resident not receiving the recommended nutritional support, as evidenced by the weight fluctuations recorded in the resident's weight summary report.
Failure to Maintain and Monitor Peripheral IV Catheter
Penalty
Summary
The facility failed to provide proper care and maintenance of a peripherally inserted IV catheter for a resident, identified as Resident #70, who was admitted with diagnoses including heart failure and hypertension. The deficiency was observed when the facility did not consistently flush the peripheral IV catheter and failed to monitor the IV site for complications. The facility's policy required specific physician's orders for flushing the catheter, which were not documented in Resident #70's medical records. The resident reported that the IV catheter had not been flushed since the IV fluids were discontinued. Nurse #4 confirmed that there should have been a physician's order to monitor the IV site for complications and to flush the catheter to maintain patency, but these orders were not in place. The Director of Nursing also stated that orders should have been in place to monitor the IV site and to flush the catheter at least twice daily when not infusing fluids. The lack of these orders and actions led to the deficiency in care for Resident #70.
Failure to Maintain Clean Oxygen Filter for Resident with COPD
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident diagnosed with chronic obstructive pulmonary disease (COPD) with hypoxia and hypercapnia, who was dependent on oxygen. The deficiency was identified when a surveyor observed the resident using a nasal oxygen cannula connected to an oxygen concentrator with a visibly dirty filter, covered with a thick layer of dust. This observation was made despite the facility's policy and the physician's order requiring the oxygen filter to be cleaned regularly. The resident, who was cognitively intact, was being weaned off oxygen, with the concentrator set at a flow rate of 1.5 liters per minute. The physician's order specified that the oxygen filter should be rinsed, patted dry, and replaced weekly, and the Director of Nursing confirmed that this was the expected practice. However, the failure to clean the oxygen filter as ordered was confirmed through interviews with the nursing staff, indicating a lapse in following the prescribed respiratory care protocol.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to ensure proper dialysis care and services for residents requiring such treatment. Specifically, the facility did not obtain physician orders for dialysis treatment and post-dialysis weights for one resident, and failed to obtain post-dialysis weights for two other residents. This deficiency was identified during a review of the facility's Dialysis Management policy and interviews with staff members. Resident #77, admitted with acute kidney failure and type 2 diabetes, did not have active physician orders for dialysis treatment or post-dialysis weights. The resident was weighed inconsistently, with only two recorded weights in August and three in September. Interviews with Nurse #3 and the Director of Nursing revealed a lack of awareness regarding the absence of physician orders and the failure to obtain weights for this resident. Resident #117, readmitted with dependence on renal dialysis and type 2 diabetes, also experienced issues with weight documentation. Despite having physician orders for pre and post-dialysis weights, the resident was weighed only four times in August and twice in September. The dialysis communication binder for this resident was found to be blank, indicating a possible misplacement of previous records. Similarly, Resident #372, admitted with end-stage renal disease, had discrepancies in recorded post-dialysis weights between the Medication Administration Record and the dialysis communication book, highlighting inaccuracies in weight documentation.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by an incident involving one resident out of four observed. During a medication pass observation, Nurse #1 made two errors out of 32 opportunities, resulting in a medication error rate of 6.25%. Specifically, Nurse #1 administered the incorrect form of aspirin and the incorrect dose of calcium plus vitamin D3 to Resident #89. The facility's policy on medication administration requires that the correct medication be administered by verifying the physician's order and the medication label. Resident #89, who was admitted to the facility with diagnoses including heart failure and hypertension, was observed receiving medications that did not match the physician's orders. The resident's orders specified an aspirin 81 mg chewable tablet and a calcium 600 mg/5 mcg vitamin D3 tablet. However, Nurse #1 administered an enteric-coated aspirin and a calcium 600 mg/10 mcg vitamin D3 tablet. During interviews, Nurse #1 admitted to being unaware that medications needed to be in the form ordered by the physician, and the Director of Nursing confirmed that the medication form and dose should match the physician's order.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control program, specifically in the area of hand hygiene during wound care. Observations revealed that Nurse #2 and CNA #4 did not perform hand hygiene after removing gloves while attending to a resident with multiple wounds on the left leg. The resident's wounds had a significant amount of bloody drainage, and during the care process, both staff members repeatedly changed gloves without washing or sanitizing their hands in between. This included instances where Nurse #2 removed soiled gloves to handle an electronic tablet and to open dressing packages, and CNA #4 removed gloves to assist with taking photographs, all without performing hand hygiene. Interviews with the staff involved confirmed the oversight, with both Nurse #2 and CNA #4 acknowledging the failure to perform hand hygiene as required by the facility's policy. Nurse #2 admitted forgetting to bring sanitizer into the room, which contributed to the lapse. The Director of Nursing also confirmed that hand hygiene should be performed every time gloves are removed and before new gloves are applied during wound care, highlighting a clear deviation from the established protocol.
Failure to Transmit MDS Discharge Assessments Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) discharge assessments to the Centers for Medicare and Medicaid Services (CMS) System within the required timeframe for two residents. According to the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, MDS discharge assessments must be transmitted within 14 days after completion. However, for Resident #18, who was admitted with diagnoses including low back pain and repeated falls, the MDS discharge assessment was completed on 5/14/24 but was never transmitted. Similarly, for Resident #99, admitted with diagnoses including adult failure to thrive and repeated falls, the MDS discharge assessment was completed on 5/16/24 but was also never transmitted. Interviews with facility staff revealed that the Director of Nursing (DON) acknowledged that all MDS assessments should be transmitted timely by an MDS Nurse as per RAI guidelines. MDS Nurse #1 confirmed that the MDS discharge assessments for both residents were completed but not transmitted as required. This oversight resulted in a failure to comply with the mandated timeline for transmitting MDS data, as outlined in the CMS guidelines.
Inaccurate MDS Coding for Resident's Cognitive Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, leading to a deficiency in the assessment process. The resident, admitted in April 2023 with a diagnosis of traumatic subdural hemorrhage, was inaccurately coded as comatose or in a persistent vegetative state in the MDS assessment dated September 6, 2024. This coding error resulted in the resident's hearing, speech, vision, cognitive patterns, mood, activity preferences, and pain not being assessed. Observations and interviews conducted by the surveyor revealed that the resident was able to answer questions, follow commands, and engage with electronic devices, indicating a level of awareness and interaction inconsistent with the MDS coding. Interviews with facility staff, including a nurse practitioner, a nurse, a certified nursing aide, and the Director of Nursing, confirmed that the resident had shown improvement since admission and was able to communicate effectively. The MDS nurse acknowledged the discrepancy, noting that the MDS coding was based on the nursing clinical evaluation assessment, which should reflect the resident's current status. The Director of Nursing also confirmed that the resident was not in a vegetative state and that the MDS should accurately represent the resident's condition.
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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