Worcester Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Worcester, Massachusetts.
- Location
- 119 Providence Street, Worcester, Massachusetts 01604
- CMS Provider Number
- 225199
- Inspections on file
- 27
- Latest survey
- October 21, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Worcester Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
A resident experienced an unwitnessed fall with emesis during the night and later showed a decline in condition, becoming unrousable. Nursing staff assessed the resident and initiated neurological monitoring but did not notify the provider until several hours after the initial incident and subsequent decline, contrary to facility policy requiring prompt notification of significant changes in condition.
A resident with mild cognitive impairment and the ability to make their own medical decisions was not given the opportunity to review or sign documents related to advanced directives, psychotropic medication, vaccination education, and ancillary services. Instead, all consents were signed by the resident's representative, even though the healthcare proxy had not been invoked. Facility staff confirmed that the resident should have signed these documents personally.
A resident with mobility and gait issues was repeatedly observed alone in bed with the call light out of reach, despite being cognitively intact and care plans requiring the device to be accessible. Staff and DON interviews confirmed the expectation for call lights to be within reach, but this was not followed, leaving the resident unable to request assistance as needed.
A resident with diabetes, hypertension, and schizophrenia did not receive prescribed eyeglasses after an optometrist's recommendation, despite a valid prescription and guardian consent. Facility staff failed to follow up on the consultant's recommendation, leaving the resident without needed vision correction.
A resident with limited ROM and mobility needs did not receive staff-assisted ambulation as recommended by PT after discharge from skilled services. Although staff were in-serviced on the resident's walking plan, care documentation was not updated, and the resident was not walked or assisted to the bathroom, resulting in an avoidable decline in mobility.
Staff did not consistently measure or document the external length of a PICC line for a resident receiving IV antibiotics for endocarditis and sepsis, as required by physician orders and facility policy. The DON confirmed that weekly measurements were not performed, and documentation was missing for several scheduled dressing changes.
A resident with multiple mental health diagnoses and recent hospitalization for suicidal ideation did not receive follow-up behavioral health services as recommended by a provider and ordered by a physician. Despite care plan interventions and facility policy requiring referral and documentation, the resident was not referred to the psychiatric consultant team, and staff interviews confirmed this omission.
Staff on one unit did not properly document prescription numbers, fill dates, or transfer page numbers in the Controlled Substance Register when new controlled medications were entered or information was transferred to a new page. Both a nurse and the DON confirmed that required documentation procedures were not followed, resulting in incomplete records for controlled substances.
Staff did not accurately document the daily total amount of enteral feeding administered to a resident with a gastrostomy, despite facility policy requiring such documentation. Both the dietician and ADNS confirmed that the resident's enteral fluid intake was not properly recorded, and no evidence of this documentation was found in the clinical record.
Staff assisting with meal service failed to perform hand hygiene after handling dirty dishware and before serving food and beverages, despite the availability of hand hygiene resources and prior training. Activity assistants and other staff were observed clearing tables and serving residents without sanitizing their hands, contrary to facility policy and infection prevention protocols.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment for residents. Observations included disrepair and unclean conditions in resident rooms and common areas, such as chipped paint, exposed screws, broken blinds, and malfunctioning bathroom fixtures. Residents reported ongoing issues with leaks and ineffective toilets. The facility's leadership acknowledged the deficiencies.
The facility failed to maintain a sanitary environment in its nourishment kitchens and main kitchen, risking food-borne illness for residents. Observations revealed peeling wallpaper, stained ceilings, and dirty microwaves in nourishment kitchens, with unlabeled food items in refrigerators. The main kitchen's dish room had a foul odor, flying insects, and a non-functional dishwasher, with a dietary aide improperly sanitizing a meal cart. Staff interviews confirmed the unsanitary conditions, and the need for thorough cleaning and equipment replacement was acknowledged.
The facility's QAPI program failed to ensure a clean, safe, and homelike environment, with ongoing issues in pest control and non-functional call lights. Despite identifying these problems, the facility did not resolve them effectively, as highlighted in the QAPI meeting minutes and an audit. The administrator acknowledged the need for more detailed measures to address these issues.
The facility failed to maintain a functional resident call system across multiple units, with numerous call lights non-functional and alternative communication devices like hand bells either missing or broken. Residents reported having to call out or physically seek staff assistance due to the lack of a working system. The administration acknowledged the ongoing issue, which had been known since before March 2024, but had not yet resolved the deficiencies.
The facility failed to maintain an effective pest control program, leading to an ongoing infestation of mice and German cockroaches in resident care areas. Pest control services were not conducted for several months, and observations revealed numerous pests in the kitchen and resident rooms. Residents reported discomfort due to the pests, and staff interviews highlighted a lack of communication and awareness regarding pest control efforts.
The facility failed to resolve resident grievances about cold food served by the Dietary Department. Despite ongoing complaints over two months, meals continued to be served on Styrofoam plates due to a non-functional dishwasher. The Food Service Director acknowledged the issue but did not implement changes, and the Administrator was aware of the delay in dishwasher installation, leading to unresolved resident dissatisfaction.
A resident with Type 2 Diabetes and Dementia did not receive proper diabetic foot care, resulting in excessively long and curled toenails. Despite care plans requiring podiatry consults, the facility failed to document refusals or notify the resident's representative and healthcare providers. Staff interviews revealed a lack of awareness and action, and the facility's administration acknowledged the oversight.
A resident at risk for nutritional decline experienced an undesired weight gain due to the facility's failure to monitor and record weights as per policy. Despite a care plan to maintain stable weight and achieve weight loss, the resident's weight was not recorded weekly post-admission or monthly thereafter. The issue was only identified when the resident reported the weight gain to the RD, who confirmed the facility's policy was not followed.
A surveyor observed that a handrail in the corridor between the Nurse's Station and the Nourishment Kitchen was loose and unattached, creating a gap and posing a potential safety hazard to residents. The Administrator confirmed that all handrails should be secured to the wall.
A resident did not receive 15 doses of Suboxone over five days because nursing staff failed to notify the Physician that the medication was unavailable. Multiple nurses were aware of the issue but did not inform the Physician, and the Facility lacked a specific policy for such notifications.
A resident did not receive their prescribed Suboxone for multiple days, missing a total of 15 doses. Nursing staff documented that the medication was administered when it was not, and the provider was not notified immediately about the unavailability of the medication. The resident had a history of cocaine use disorder and moderately impaired cognition.
The Facility failed to maintain accurate medical records for a resident prescribed Suboxone, documenting its administration despite the medication being unavailable. Nursing staff admitted to erroneously signing off on the MAR, and the first prescription was not received until several days after the initial orders.
The facility failed to provide a safe, clean, comfortable, and homelike environment across four units. Observations included damaged walls, soiled curtains, stained ceilings, leaky sinks, missing mirrors, loose toilets, and strong urine odors. The Maintenance Director acknowledged the need for repairs and replacements, confirming ongoing issues in maintaining a homelike environment for residents.
The facility failed to ensure accurate MDS coding for several residents, including errors related to Hospice services, Significant Mental Illness, pressure ulcers, use of physical restraints, and communication abilities. These inaccuracies were confirmed through documentation reviews and staff interviews.
The facility failed to monitor and document fluid intake and output for a resident with cirrhosis as ordered, despite the facility's policy requiring such documentation each shift and daily totals on the MAR. The deficiency was confirmed by the DON and observed during a survey when the resident was seen with leg swelling.
The facility failed to ensure that psychiatric medication recommendations for a resident were reviewed by the Attending Physician, resulting in delayed management of anxiety and pain symptoms. Staff were unaware of the recommendations due to a lapse in the process of checking and approving consultant notes in the electronic health record (EHR).
The facility failed to provide necessary ADL assistance for two residents. One resident with vascular dementia had long, dirty fingernails despite requests for care, and another resident with Alzheimer's disease had long facial hair despite a physician's order to shave. Interviews revealed inconsistencies in care provision and documentation.
The facility failed to ensure a resident with right hemiparesis wore a prescribed hand splint to prevent contracture. Despite documentation indicating daily application, observations and interviews revealed the splint was missing and not used for an extended period. Staff were unaware of the splint's whereabouts, and the issue was only addressed after surveyor intervention.
The facility failed to provide proper care and maintenance for vascular access devices for two residents. One resident did not have physician orders for the care of a midline catheter, and another resident's PICC line measurements were not documented as required.
A resident with COPD had a physician's order for oxygen at 2 LPM via nasal cannula, but the facility staff repeatedly set the oxygen concentrator to 3 LPM. The resident was aware of the correct setting, and a nurse confirmed the discrepancy, indicating a failure to follow the physician's order.
The facility failed to ensure that a resident with PTSD had a care plan that included their identified PTSD triggers, leading to retraumatization when a male staff member put his hand on the resident's shoulder. The resident's care plan did not include specific PTSD triggers, despite the social worker's acknowledgment that it should have.
The facility failed to obtain physician orders for a resident's surgical wound care treatment after the removal of a VAC device. The resident's wound was managed without clear directives from a physician, contrary to the facility's policy on skin and wounds.
The facility failed to monitor the side effects and adverse reactions of psychotropic medications for three residents, despite care plans requiring such monitoring. Interviews confirmed that the required monitoring was not performed.
The facility failed to offer the Pneumococcal Conjugate Vaccine (PCV) to a resident at the time of admission or shortly thereafter, despite the resident having no medical contraindications and being at risk for pneumonia. The Infection Preventionist acknowledged the oversight and admitted that a system for tracking Pneumococcal vaccinations had not yet been developed.
The facility failed to maintain a functioning call system in five resident rooms on Unit Two and did not provide an alternative communication method for a resident. The call bell system had been malfunctioning for several months, and the necessary repairs were still pending.
Failure to Timely Notify Provider After Resident Fall and Condition Decline
Penalty
Summary
Nursing staff failed to notify the resident's provider in a timely manner following an unwitnessed fall and episode of emesis during the overnight shift. The resident, who had a history of diabetes, difficulty walking, sleep apnea, and schizoaffective disorder, was found on the floor in emesis at approximately 2:00 A.M. by nursing staff. The nurse assessed the resident, determined there were no complaints of pain, and initiated neurological monitoring, but did not notify the provider of the incident at that time. Later in the morning, the resident reported feeling unwell and weak to a CNA, who relayed this information to the nurse. At around 8:00 A.M., the nurse found the resident to be unrousable but breathing, indicating a decline in condition. Despite these significant changes, there was no documentation that the provider was notified until approximately 9:00 A.M., when the nursing supervisor was informed and subsequently contacted the provider, who ordered the resident to be sent to the hospital emergency department. Interviews with staff confirmed that the nurse did not notify the on-call provider during the overnight shift regarding the fall, emesis, or the resident's subsequent decline. The facility's policy required prompt notification of the provider in the event of a significant change in condition, which was not followed in this case. Documentation and staff statements corroborated that the required notifications were delayed.
Failure to Obtain Informed Consent from Resident with Decision-Making Capacity
Penalty
Summary
The facility failed to ensure that a resident, who was determined to have the capacity for informed medical decision-making, was given the opportunity to review and sign documents related to their medical care. Upon admission, consent forms for services such as audiology, eye care, podiatry, dental, behavioral health, vaccination education, psychotropic medication, and the MOLST (Medical Orders for Life Sustaining Treatment) were all signed by the resident's representative, despite the resident's healthcare proxy not being invoked and the resident being capable of making their own decisions. The facility's own admission procedures require that residents who are capable should be provided with information and the opportunity to execute advance directives and other consents themselves, with documentation in the medical record. Record review showed that the resident had a mild cognitive impairment but was able to communicate in English and Spanish, and the social worker confirmed with the hospital that the resident's healthcare proxy had not been activated. Interviews with facility staff, including the social worker and the assistant director of nursing, confirmed that the consents should have been signed by the resident, not the representative. The failure to follow proper procedures resulted in the resident not being fully informed or able to participate in decisions regarding their care and treatment documentation.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
Facility staff failed to provide appropriate access to the call light for one resident, despite facility policy and the resident's care plan requiring the call light to be within reach. The resident, who was cognitively intact and had diagnoses including abnormalities of gait, mobility issues, and weakness, was observed multiple times lying in bed with the call light hanging on the wall out of reach. The resident was alone in the room and unable to access the call light to request staff assistance. Interviews confirmed that the resident relied on the call light for help and was unable to locate or reach it during the surveyor's observations. Staff interviews, including with a CNA and the DON, confirmed that the expectation was for call lights to be within reach of all residents after care and whenever staff entered or exited the room. Despite these policies and expectations, the call light remained out of reach for the resident during several observations, and staff failed to ensure its proper placement. The resident's care plan specifically identified the need for the call light to be within reach due to fall risk, but this intervention was not followed.
Failure to Provide Prescribed Eyeglasses for Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary assistive devices to maintain vision, specifically by not obtaining prescription eyeglasses as recommended by an optometrist. The resident, who had diagnoses including Paranoid Schizophrenia, Type 2 Diabetes without complications, and Hypertension, was admitted in January 2024 and had a legal guardian. An eye care consultation was completed with consent from the guardian, and the optometrist recommended new glasses for distance vision, providing a prescription and instructions for the nursing home staff to obtain the glasses. Despite these recommendations, the resident's clinical record and progress notes showed no evidence that the prescription for eyeglasses was filled. The resident remained without glasses, as confirmed by both the resident and facility documentation. The Director of Nursing acknowledged that staff did not follow up on the optometrist's recommendation, and no documentation was provided to show that the necessary steps were taken to acquire the glasses for the resident.
Failure to Implement Functional Mobility Program After PT Discharge
Penalty
Summary
A deficiency occurred when facility staff failed to implement a functional mobility program for a resident with limited range of motion (ROM) and mobility needs, as recommended by Physical Therapy (PT) upon discharge from skilled services. The resident, who had diagnoses including Type II Diabetes with diabetic neuropathy, Myasthenia Gravis, and difficulty walking, was cognitively intact and had been receiving PT and Occupational Therapy. PT discharge documentation indicated that the resident was able to ambulate with a rollator and required Contact Guard or Stand By Assist, and that staff had been in-serviced on the resident's ambulation plan. The PT discharge summary recommended continued out-of-bed activity and ambulation with staff assistance to maintain the resident's current level of function. Despite these recommendations and documented staff education, the resident reported that staff had not walked with them since discharge from rehabilitation services. Observations and interviews confirmed that the resident remained in bed or in a wheelchair, used briefs instead of walking to the bathroom, and was not offered opportunities to ambulate with staff. Review of the resident's CNA Care Card and documentation revealed no updates or records indicating that staff were assisting the resident with walking or transfers as recommended by PT. Nursing progress notes also lacked evidence of any plan or offers to walk with the resident. Interviews with staff, including CNAs and rehabilitation personnel, confirmed that although in-service education was provided, the care plan and CNA Care Card were not updated to reflect the PT recommendations. The Director of Nursing acknowledged that the Care Card should have been updated to communicate the resident's ambulation needs to staff, but this was not done, resulting in the resident not receiving the necessary care and services to maintain or improve mobility and ROM.
Failure to Document and Measure PICC Line Length as Ordered
Penalty
Summary
Facility staff failed to provide care and services for a peripherally inserted central catheter (PICC) in accordance with professional standards and the resident's plan of care. Specifically, staff did not measure and document the external length of the PICC line weekly as ordered by the physician and required by facility policy. Documentation review showed that the external catheter length was not recorded on several occasions when dressing changes were performed, and there were instances where neither the dressing change nor the measurement was completed as scheduled. The Lippincott Manual of Nursing Practice and facility policies both require regular measurement and documentation of the external catheter length to monitor for migration and related complications. The resident involved was admitted with acute and subacute endocarditis and severe sepsis with septic shock, and was receiving IV antibiotic therapy via a PICC line. The resident's care plan and physician orders specified weekly measurement of the external catheter length, but this was not consistently performed or documented. Interviews with the resident and the DON confirmed that the required weekly measurements were not being done, despite the importance of monitoring for PICC migration and associated medical complications.
Failure to Provide Required Behavioral Health Services After Psychiatric Recommendation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with multiple mental health diagnoses, including PTSD, schizoaffective disorder, bipolar disorder, borderline personality disorder, depressive disorder, and generalized anxiety disorder. The resident had recently been admitted to the hospital for suicidal ideation and exacerbation of bipolar symptoms, and upon return to the facility, there were documented recommendations for ongoing psychiatric management and follow-up. Despite a physician's order for psychiatric consultation and treatment, as well as care plan interventions to refer the resident to psychiatric services, there was no evidence in the clinical record that the resident had been seen by the facility's consultant psychiatric services. Interviews with facility staff confirmed that the resident should have been referred for behavioral health follow-up but was not. The resident also reported not having seen a psychiatric specialist since admission. The facility's own policy required staff to notify consultants and document responses in the medical record, but this process was not followed for this resident, resulting in a lack of necessary behavioral health services after clear recommendations and orders were made.
Failure to Accurately Document Controlled Substances in Narcotic Book
Penalty
Summary
Facility staff failed to maintain accurate records of controlled substances on the 5th Floor Unit, as required by both facility policy and federal and state regulations. Specifically, when new controlled medications were entered into the Controlled Substance Register (Narcotic Book) or when information for a medication was transferred from one page to another, staff did not complete the required documentation. The headings of each page in the register were missing critical information such as prescription numbers, fill dates, and transfer page numbers. This was confirmed during a review of the Controlled Substance Log by a surveyor and a nurse, who found that none of the reviewed pages had the necessary information filled in. Interviews with both a nurse and the Director of Nursing (DON) confirmed that the facility's procedures require the prescription number and date filled to be logged and transferred appropriately when a new page is started in the Controlled Medication Log. However, these steps were not followed, resulting in incomplete documentation for controlled substances. The deficiency was limited to the 5th Floor Unit out of four units reviewed, and no specific residents or patient conditions were mentioned in relation to the deficiency.
Failure to Accurately Document Enteral Feeding Intake
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for one resident who had a gastrostomy and was receiving enteral feedings. The facility's policies required staff to document the procedure, including the intake, flush, and free water volume administered, as well as to ensure that nursing documentation was clear, concise, and included information related to the resident's condition and care provided. Despite these requirements, review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) for the relevant months did not show documentation of the total amount of enteral formula administered daily to the resident. Interviews with facility staff, including the dietician and the Assistant Director of Nursing (ADNS), confirmed that the resident's enteral fluid intake was not being accurately documented. The dietician stated that she relied on this documentation to monitor the resident's daily intake, and the ADNS acknowledged that the staff had not been recording the total enteral fluid intake as required. No evidence was found elsewhere in the clinical record to indicate that this information was being documented.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to maintain appropriate hygiene practices during meal service in the 1st Floor dining room, as observed by surveyors. Nine staff members, including activity assistants, dietary aides, and medical record personnel, were present to assist with meal service. Despite the presence of hand hygiene resources such as alcohol-based hand sanitizer dispensers and a sink with soap and paper towels, several staff members did not perform hand hygiene at critical points during the meal service. Specifically, activity assistants were observed clearing used utensils, plates, and cups from tables, wiping tables, and placing dirty dishware in bins without wearing gloves or performing hand hygiene afterward. These same staff members then returned to serving food and beverages to residents without sanitizing their hands. Additionally, when serving ice cream from a communal container, the activity assistants did not perform hand hygiene before handling and distributing the items to residents. Interviews with staff and leadership confirmed that all staff had been trained on hand hygiene protocols and were aware of the importance of sanitizing hands between tasks, especially during meal service. The Director of Nursing and Infection Preventionist both stated that the expectation was for staff to use gloves when handling dirty items and to perform hand hygiene after glove removal or between serving residents. Despite this, the observed actions did not align with facility policy or training, resulting in a failure to prevent potential contamination and the spread of foodborne illnesses.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as observed during a survey. The surveyors noted various stages of disrepair, aging, and unclean conditions in common areas, resident rooms, and care areas. These included black streaks, gouges, chipped and peeling paint on walls, stained and grimy vinyl baseboards, and exposed spackle. Additionally, there were issues with bathroom fixtures, such as non-functional lights, exposed screws, and missing sections of baseboard heaters, which created potentially hazardous conditions. In several resident rooms, the surveyors found broken window blinds, missing drawer handles, and damaged walls with exposed screws and spackle. The heating and air conditioning units were often rusted, loose, or pulling away from the walls, and some rooms had broken or missing closet slats. The surveyors also observed standing water, leaking sinks, and toilets that did not flush effectively, which residents reported had been ongoing issues that were not addressed by the facility staff. The environmental conditions extended to other units, where surveyors found peeling paint, rust, and jagged edges on baseboard heaters, as well as broken closet doors and missing window screens. Insects were present in some rooms, and there were issues with ceiling tiles, including stains and unfinished spackle. During a group interview, the facility's Administrator, Director of Housekeeping, and Plant Manager acknowledged the deficiencies, with the Administrator admitting that improvements were needed and the Plant Manager agreeing that the environment was not adequately maintained.
Unsanitary Conditions in Facility Kitchens
Penalty
Summary
The facility failed to maintain a sanitary environment in its nourishment kitchens and main kitchen, which placed all residents at risk for food-borne illness. Observations revealed multiple issues across four nursing units and the main kitchen. In the nourishment kitchens, there were instances of peeling wallpaper with brown and black stains, separated kick-plates, and ceiling tiles that were not flush, creating gaps. Additionally, there were large stains on the ceiling tiles and walls, debris in light fixtures, and dirt accumulation in corners. The refrigerators contained unlabeled and undated food items, and microwaves were found to be dirty and rusty, with particles that could fall into food. Interviews with staff confirmed the unsanitary conditions. CNA #2 and CNA #4 acknowledged the presence of dirty and rusty microwaves, and the Director of Housekeeping admitted that the microwaves needed replacement and that the nourishment kitchens required thorough cleaning. The Administrator and Director of Housekeeping also recognized the need for ceiling tile replacement and overall cleanliness improvements. In the main kitchen's dish room, a foul odor was noted, along with flying insects and a thick black substance on the garbage disposal. The Food Service Director attributed the odor to stagnant drains and pipes due to a non-functional dishwasher. Despite the unsanitary conditions, a dietary aide was observed sanitizing a meal cart in the dish room, which was acknowledged as inappropriate by the Food Service Director. The Administrator confirmed the insect problem and odor, stating that the dish room required thorough cleaning before the dishwasher could be put back into service.
Deficiencies in QAPI Program and Facility Maintenance
Penalty
Summary
The facility failed to maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program, which resulted in an environment that did not promote a clean, safe, and homelike atmosphere for residents. The QAPI policy, dated April 2015, outlined the need for a systematic approach to address all systems of care, including clinical care, quality of life, and resident choice. However, the facility's QAPI meeting minutes from June to August 2024 revealed ongoing issues with pest control and non-functional call lights, which were not adequately addressed. Despite the facility's policy to use a structured approach to identify and resolve problems, the pest control services were inconsistent, with no visits recorded in June and July 2024, contrary to the monthly service claims in the QAPI meeting minutes. Additionally, the facility's audit on October 1, 2024, highlighted significant issues with the call light system, with numerous rooms across multiple units having non-working call lights. This problem had been identified months prior but remained unresolved at the time of the survey. The administrator acknowledged the need for more detailed QAPI measures to combat pest infestations and admitted that the call light issues should have been resolved earlier. The lack of effective implementation and maintenance of the QAPI program contributed to the deficiencies observed during the survey.
Non-Functional Resident Call System Across Multiple Units
Penalty
Summary
The facility failed to ensure a functional resident call/communication system across all four resident units, as observed and reported by surveyors. The facility's policy mandates that all residents have access to a call light or alternative communication device when unattended, and any defective call lights should be reported and repaired promptly. However, during the survey, it was found that numerous call lights were non-functional across multiple units, with Unit 2 having a completely non-functioning system, and significant numbers of call lights not working on Units 3, 4, and 5. During the survey, specific rooms were identified where call lights were either missing or not functioning, and alternative communication methods like hand bells were not provided or were broken. For instance, in Unit 5, rooms were found with missing buttons or non-functioning call lights, and in Unit 4, the call system was not alerting staff correctly, leading to potential delays in care. Interviews with residents revealed that many had to resort to calling out for help or physically going to find staff due to the lack of a working call system. The facility's administration acknowledged the ongoing issues with the call light system, which had been known since before March 2024. Despite having received quotes for system replacement, the necessary actions to resolve the deficiencies had not been taken, leaving residents without reliable means to request assistance. The administrator admitted that the call light system was a significant problem, with some units requiring complete replacement, and that not all residents had access to alternative communication devices like hand bells, which were frequently broken.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an ongoing infestation of mice and German cockroaches in several resident care areas. Despite having a known active infestation from the end of May to the beginning of August, pest control services were not conducted during this period. The facility was unable to provide policies related to maintaining a clean environment or pest control, and pest control service visits were sporadic, with significant gaps in service. Observations during the survey revealed numerous instances of pest presence, including dead mice and live cockroaches in various areas such as the kitchen and resident rooms. Residents reported discomfort and distress due to the presence of pests, with some residents noting frequent sightings of mice and cockroaches in their rooms. The surveyors also observed flying insects in multiple units and the main kitchen dish room, indicating a widespread issue. Interviews with facility staff, including the Food Service Director and the Administrator, highlighted a lack of communication and awareness regarding the pest control efforts. The Food Service Director was not informed of the pest control findings or recommendations, and the Administrator was initially unaware of the extent of the flying insect problem. The Director of Housekeeping, responsible for pest control, did not know why pest control visits were missed and expressed uncertainty about further actions to address the issue. The Administrator acknowledged the need for more effective measures to combat the pest problems.
Failure to Address Resident Grievances on Cold Food
Penalty
Summary
The facility failed to address and resolve resident grievances related to the Dietary Department in a timely manner. Over the course of two months, residents consistently reported issues with cold food during Resident Council Meetings. Despite these complaints being forwarded to the Food Service Director (FSD), the problem persisted. The facility's dishwasher was non-functional, and meals were served on Styrofoam plates, which contributed to the food being cold. The FSD acknowledged receiving complaints but did not implement any test meal trays or protocol changes to address the issue. Interviews with residents confirmed that hot food items were usually served cold, and meals had been served on Styrofoam for several months. The Administrator was aware of the complaints and the delay in installing the new dishwasher, which required a custom fit. Attempts to use regular plates were deemed unsustainable, leading to continued use of Styrofoam. The facility's inaction and reliance on the pending dishwasher installation resulted in unresolved grievances and ongoing dissatisfaction among residents.
Failure to Provide Diabetic Foot Care
Penalty
Summary
The facility failed to provide appropriate diabetic foot care for a resident with Type 2 Diabetes and Dementia, who was at risk for developing diabetes-related foot complications. The resident's toenails were found to be excessively long, discolored, and curled, resembling 'vulture's claws,' as described by a witness. Despite having a care plan that required diabetic foot care and podiatry consults, the facility did not ensure that the resident received the necessary care. The resident was placed on a 'Do Not Treat' list by the contracted podiatrist due to repeated refusals, but there was no documentation of these refusals or notifications to the resident's representative or healthcare providers. Interviews with staff revealed a lack of awareness and action regarding the resident's foot care needs. Certified Nurse Aides (CNAs) and nurses were aware of the resident's long toenails but did not take appropriate steps to address the issue. The facility's policy required diabetic foot care to be performed by nurses and documented in the Treatment Administration Record (TAR), but this was not done. The resident's care plan also lacked personalized interventions for activities of daily living (ADL) care, diabetic foot care, or behaviors, contributing to the oversight. The facility's administration, including the Unit Manager and Director of Nurses (DON), acknowledged the failure to document refusals and notify relevant parties. The Administrator admitted to cutting the resident's toenails himself after being informed by the family, but this action was not documented in the medical record. The contracted podiatrist confirmed that the resident's toenails had been trimmed before his visit, indicating non-professional intervention, which he deemed hazardous for diabetic patients. The lack of proper documentation and communication among staff and with the resident's family and healthcare providers led to the deficiency in care.
Failure to Monitor Resident's Weight Leads to Undesired Weight Gain
Penalty
Summary
The facility failed to ensure the accurate assessment and monitoring of a resident's nutritional status, leading to an undesired weight gain. The resident, who was at risk for nutritional decline due to a recent below-the-knee amputation, anemia, multiple food allergies, and preferences, was admitted with a weight of 150 lbs. The care plan included goals for maintaining a stable weight and achieving a 5% weight loss. However, the facility did not adhere to its policy of obtaining and recording the resident's weight weekly for the first four weeks post-admission and monthly thereafter. The Treatment Administration Record (TAR) showed that the resident's weight was recorded only on the admission date and not on the subsequent weekly dates as required. Additionally, there was no physician's order to obtain monthly weights in September, contrary to the facility's policy. The Registered Dietician (RD) was only made aware of the resident's significant weight gain of nearly 40 lbs. when the resident expressed concern and requested to be seen. The RD confirmed that the facility's policy was not followed, and the weight gain was not identified until the resident's request. Interviews with the Unit Manager and Director of Nurses (DON) revealed that the Certified Nurse Aides (CNAs) were responsible for obtaining and recording weights, while nursing staff were to enter them into the electronic medical record (EMR). However, due to a busy unit, the Unit Manager or Assistant Director of Nurses (ADON) entered the weights instead of the charge nurse. The DON acknowledged the failure to obtain weights as ordered and recognized the need for improvement in this area.
Unsecured Handrail Poses Safety Hazard
Penalty
Summary
The Facility failed to ensure the handrail in the corridor between the Nurse's Station and the Nourishment Kitchen on Unit 3 was properly secured to the wall. During an environmental tour, a surveyor observed that the handrail was loose and unattached, creating a gap between the end of the railing and the wall. This condition posed a potential safety hazard to residents. The Administrator confirmed in an interview that all handrails should be secured to the wall.
Failure to Notify Physician of Unavailable Medication
Penalty
Summary
The Facility failed to ensure nursing notified a resident's Physician when their medication, Suboxone, was unavailable to be administered in accordance with Physician orders. As a result, the resident did not receive their scheduled doses for five days, missing a total of 15 doses. The resident had a history of cocaine use disorder (in remission) and was admitted to the Facility in April 2024 with a Physician's Order for Suboxone Sublingual Film 8-2 mg to be administered three times a day. The Medication Administration Record (MAR) indicated that the Suboxone was not administered on multiple dates, and the MAR was initialed and signed off by nursing with charting code 9, which indicated to see the Nurse's Notes. However, there was no documentation in the Nurse's Notes for some of these dates, and no notification was made to the Physician about the unavailability of the medication until several days later. Interviews with nursing staff revealed that multiple nurses were aware that the Suboxone was unavailable but did not notify the Physician. Nurse #1 and Nurse #2 both acknowledged that they did not inform the Physician about the unavailability of the medication. The Nursing Supervisor admitted that she got side-tracked and forgot to follow up on the issue. Nurse #4 also did not notify the Physician, believing that the medication was on order based on information from other nursing staff. The Nurse Practitioner (NP) confirmed that she was not informed about the need for a prescription for Suboxone or that the resident had missed doses until several days later. The Director of Nurses (DON) stated that nursing should have notified the resident's provider immediately when the Suboxone was not administered as ordered and when it was identified that the medication was unavailable. The Facility did not have a specific policy for Physician notification related to medications being unavailable or not administered, as it was considered a basic standard of nursing practice. The failure to notify the Physician resulted in the resident missing 15 doses of Suboxone over five days.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the resident did not receive their prescribed Suboxone for multiple days, missing a total of 15 doses. The resident had a physician's order for Suboxone to be administered three times a day, but the medication was not available, and nursing staff documented that the medication was administered when it was not. This failure placed the resident at increased risk for adverse side effects due to the abrupt discontinuation of the medication. The resident was admitted to the facility with a history of cocaine use disorder and had a cognitive assessment indicating moderately impaired cognition. Despite the physician's order for Suboxone, the medication was not administered on several occasions, and the nursing staff used a charting code to indicate the medication was unavailable. However, there was no documentation in the nurse's notes for some of the missed doses, and the nursing staff did not notify the resident's provider immediately about the unavailability of the medication. Interviews with the nursing staff and the pharmacy manager revealed that the first prescription for Suboxone was received by the pharmacy six days after the resident's admission. The Director of Nurses acknowledged that nursing should have notified the provider immediately and should not have documented that the medication was administered when it was not. The Nurse Practitioner confirmed that the resident missed several doses of Suboxone and emphasized that not even one dose should be missed.
Failure to Maintain Accurate Medical Records for Narcotic Medication
Penalty
Summary
The Facility failed to maintain a complete and accurate medical record for a resident who had a Physician's Order for Suboxone, a narcotic medication used for opioid dependence. Despite the medication being unavailable at the Facility, nursing staff documented that the medication was administered on multiple occasions. Specifically, the MAR indicated that the Suboxone was administered on 04/26/24, 04/27/24, and 04/28/24, even though the first prescription for the medication was not received until 04/30/24, and the first entry in the Controlled Substance Log was on 05/01/24. Interviews with nursing staff revealed that they had erroneously documented the administration of Suboxone. Nurse #1, Nurse #2, and the Nursing Supervisor all admitted to signing off on the MAR for the administration of Suboxone when it was not available. The Nurse Practitioner confirmed that the prescription was sent to the pharmacy on 04/30/24, resulting in several missed doses. The Director of Nurses acknowledged that nursing staff should not have documented the administration of the medication when it was not available.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents across four units. On Unit Two, the surveyor observed damage to the walls, soiled curtains, stained ceiling tiles, and a leaky bathroom sink. The Maintenance Director acknowledged that the wall repairs were inadequate, the curtain should have been cleaned, and the ceiling tile replaced. A resident reported that the bathroom sink continuously leaked, requiring frequent emptying of a basin placed underneath to catch the water. The surveyor confirmed the leak during an observation, noting greyish water collecting in the basin under the sink. On Unit Three, the surveyor noted missing mirrors, stained and damaged ceilings, damaged walls, loose toilets, and soiled curtains. Specific observations included missing mirrors in bathrooms, ceilings with patched plaster and stains, damaged walls, and unsecured toilets. The Maintenance Director confirmed the need for repairs and replacements, including drapery hooks, stained drapes, and damaged ceilings. The surveyor also observed that several rooms had not changed since the initial observation, indicating ongoing issues. On Unit Four, the surveyor found broken closet doors, a strong urine odor, and damaged walls. The Maintenance Director acknowledged the need for repairs and confirmed the strong urine smell. On Unit Five, a resident reported a leaking bathtub faucet that created a puddle on the floor, posing a slip hazard. The Maintenance Director confirmed the leak and noted that parts were needed to fix it. The surveyor's observations across all units highlighted significant deficiencies in maintaining a homelike environment for residents.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) Assessments were coded accurately for several residents. For Resident #135, the MDS Assessment was inaccurately coded regarding the resident receiving Hospice services, despite documentation and staff confirmation that the resident was on Hospice at the time of the assessment. Similarly, Resident #3's MDS Assessment was inaccurately coded concerning a Significant Mental Illness (SMI), even though the Preadmission Screening and Resident Review (PASRR) Level II indicated the presence of an SMI. The MDS Nurse acknowledged the coding error during the interview. Resident #23's MDS Assessment was incorrectly coded to indicate the presence of unhealed pressure ulcers, while the resident actually had non-pressure related diabetic ulcers. This discrepancy was confirmed through a review of the Initial Weekly Skin Audit and an interview with the MDS Nurse. Additionally, Resident #32's MDS Assessment inaccurately coded the use of side rails as a physical restraint, despite documentation showing that the side rails were used for positioning and support as per the resident's preference. Lastly, Resident #67's MDS Assessment was inaccurately coded to indicate clear speech, while the resident had documented difficulty in communication. This was observed during a surveyor's visit and confirmed by both the Unit Manager and the MDS Nurse. The resident's care plan also indicated communication difficulties, further highlighting the inaccuracy in the MDS coding.
Failure to Monitor Fluid Intake and Output
Penalty
Summary
The facility failed to implement the plan of care for a resident diagnosed with cirrhosis, specifically by not monitoring fluid intake and output as ordered. The facility's policy required intake and output to be documented each shift and totaled daily, with the 24-hour totals transcribed to the Medication Administration Record (MAR). However, a review of the clinical record flowsheets and the March 2024 MAR for the resident showed no evidence that fluid intake and output had been documented every shift as ordered. The deficiency was observed during a survey when the resident was seen with swelling in both legs. The Director of Nurses (DON) confirmed that the required documentation for fluid intake and output monitoring was not available. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15, had a physician's order for a fluid restriction of 1500 milliliters daily, which was not adhered to as per the facility's policy and the physician's orders.
Failure to Review Psychiatric Medication Recommendations
Penalty
Summary
The facility failed to maintain professional standards of practice related to psychiatric services for one resident. Specifically, the staff did not ensure that recommendations made by the Psychiatric Nurse Practitioner (NP) for medication changes were reviewed by the resident's Attending Physician. This resulted in delayed management of the resident's anxiety and pain symptoms. The facility's policy required that any health care consultant's findings and recommendations be documented and then reviewed by the attending physician, who would order the specific treatments. However, this process was not followed in the case of Resident #28, who had been admitted with diagnoses including generalized anxiety disorder, major depressive disorder, insomnia, and alcohol abuse. The Behavioral Health Group (BHG) had recommended starting Gabapentin for the resident's anxiety and neuropathic pain, but there was no evidence that this recommendation had been reviewed by the Attending Physician. Interviews with facility staff revealed that the nurse responsible was unaware of the BHG note and recommendation. The Staff Development Coordinator (SDC) explained that the BHG notes are automatically entered into the electronic health record (EHR), but the nurses or nursing supervisors need to manually check for new recommendations and get them approved by the Attending Physician. This process was not followed, leading to the oversight and delayed treatment for the resident.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living (ADLs) for two residents who required help with self-care. Resident #109, who has vascular dementia, vision loss, major depressive disorder, and a history of stroke, was observed with long fingernails containing orange/brown material. Despite the resident's requests for nail care, staff did not trim or clean the nails. Interviews with CNAs and the Activities Director revealed that nail care was not consistently provided, and there was confusion about who was responsible for this task. The Director of Nurses confirmed that CNAs should be providing nail care as part of daily ADL care. Resident #14, diagnosed with Alzheimer's disease and muscle weakness, was observed multiple times with long facial hair, despite a physician's order to shave the resident's facial hair. The resident's representative expressed a preference for the resident to be clean-shaven. Interviews with CNAs and the Unit Manager indicated that while shaving is part of personal hygiene tasks, there was no specific documentation for refusals of individual tasks. The CNA documentation and nursing progress notes showed no evidence that the resident refused personal hygiene care, including shaving. These deficiencies highlight a failure in the facility's processes to ensure that residents' ADLs, specifically grooming and personal hygiene, are adequately maintained. The lack of consistent nail care for Resident #109 and facial hair removal for Resident #14 indicates a gap in the facility's adherence to care plans and physician's orders, impacting the residents' overall well-being and dignity.
Failure to Ensure Use of Hand Splint for Resident
Penalty
Summary
The facility failed to provide care and services to prevent a decrease in range of motion (ROM) for a resident diagnosed with cerebral infarction affecting the right dominant side and right hemiparesis. The resident was prescribed a resting hand splint to prevent hand contracture, but the facility staff did not ensure the splint was applied as required. Observations and interviews revealed that the resident was frequently found without the hand splint, and staff were unable to locate it in the resident's room. Despite documentation indicating the splint was being applied daily, the resident and staff confirmed it had not been used for an extended period. The facility's policy required nursing staff to apply and remove the splint during scheduled times and to notify the rehabilitation department if the splint was worn, ill-fitting, or misplaced. However, the staff failed to adhere to these guidelines. The resident expressed willingness to wear the splint if it were available, but multiple staff members, including CNAs and nurses, could not recall the last time the splint was used or seen. The Director of Rehabilitation was only made aware of the missing splint after the surveyor's observation, indicating a lack of communication and follow-up within the facility. The Director of Nurses confirmed that the rehabilitation department had to supply a new hand splint for the resident as the original was missing. This deficiency highlights a significant lapse in the facility's adherence to its own policies and procedures, resulting in the resident not receiving the necessary care to prevent a decline in ROM and potential contracture development.
Failure to Provide Proper Care and Maintenance for Vascular Access Devices
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for two residents who required vascular access devices. For Resident #18, the facility staff did not obtain physician orders for the care and maintenance of a midline catheter. The resident had a midline catheter in the left upper arm, but there were no physician orders in place for flushing the catheter or changing the dressing, and no documentation evidence on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) indicated that care and maintenance were provided. Nurse #2 and the Staff Development Coordinator confirmed the absence of necessary physician orders and documentation. For Resident #77, the facility staff did not ensure that the external length of a Peripherally Inserted Central Catheter (PICC) was measured as ordered to monitor and prevent potential complications. The resident had a double lumen PICC in the right upper arm, with physician orders to measure the external catheter length weekly. However, there was no documentation on the MAR or in the Nursing Progress Notes indicating that these measurements were taken. The Director of Nurses confirmed the lack of evidence that the external length of the PICC line was measured as required.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD). The resident had a physician's order for oxygen at 2 liters per minute (LPM) via nasal cannula continuously. However, during multiple observations, the oxygen concentrator was set to 3.5 LPM, which was higher than the prescribed amount. The resident was aware of the correct LPM and mentioned it should be set at 2 LPM, but the staff did not adhere to this order. On three separate occasions, the surveyor observed the resident with the oxygen concentrator set incorrectly at 3 LPM. During an interview, a nurse confirmed that the physician's order was for 2 LPM and acknowledged that the oxygen should not be set higher than the prescribed amount. This failure to follow the physician's order for oxygen administration represents a deficiency in providing appropriate respiratory care for the resident.
Failure to Include PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with a history of Post Traumatic Stress Disorder (PTSD) had a care plan that included the resident's identified PTSD triggers. Specifically, the staff did not identify physical abuse as a trigger for the resident, leading to retraumatization when a male staff member put his hand on the resident's shoulder. The resident, who was cognitively intact, expressed discomfort and distress due to this action, which reminded them of past physical abuse trauma. The Social Service Trauma-Informed Care Screening Tool indicated that the resident's triggers included pain, anxiety, and other behaviors. However, the resident's care plan, initiated in October 2021, did not include these specific PTSD triggers. Interviews with the social worker confirmed that the care plan should have incorporated the resident's PTSD triggers to inform staff and prevent retraumatization. The omission of these triggers in the care plan led to the deficiency identified in the report.
Failure to Obtain Physician Orders for Wound Care Treatment
Penalty
Summary
The facility failed to provide appropriate medical care and supervision for Resident #77, who had a surgical wound on the left elbow. The resident was admitted with diagnoses including an abscess and osteomyelitis. Upon returning from a surgical follow-up appointment, the resident no longer had a Vacuum Assisted Closure (VAC) device in place for the wound treatment. However, the facility staff did not obtain new physician orders for the continued treatment of the surgical wound. Nurse #1 confirmed that there were no physician orders for wound care treatment to the resident's left elbow, and the Director of Nurses (DON) acknowledged that new wound care treatment orders should have been put into place when the resident returned from the follow-up appointment without the VAC device. Observations and interviews revealed that the resident's wound was being managed with an ABD pad and a Kerlex wrap, but there was no clear directive from a physician on how to treat the wound. The facility's policy on skin and wounds, which mandates that wound treatments be done per medical doctor order, was not followed. This lapse in obtaining appropriate medical orders for wound care treatment led to the deficiency noted in the report.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor the side effects and adverse reactions of psychotropic medications for three residents. Resident #67, who was prescribed Seroquel, Depakote, Remeron, and Gabapentin, was not monitored for side effects or adverse reactions despite the medications being administered daily. The care plan for Resident #67 included interventions to observe for drug-related adverse effects and report any negative consequences to the physician, but these were not documented in the Medication Administration Record (MAR) or clinical record for March 2024. Resident #97, who was prescribed Zyprexa, Trazodone, and Ativan, also did not have documented monitoring for side effects or adverse reactions. The care plan for Resident #97 similarly included interventions to observe for drug-related adverse effects and report any negative consequences to the physician, but these were not followed as evidenced by the lack of documentation in the MAR and clinical record for March 2024. Resident #129, who was prescribed Invega, was not monitored for side effects or adverse reactions either. The care plan for Resident #129 included interventions to observe for drug-related adverse effects and report any negative consequences to the physician, but these were not documented in the MAR or clinical record for March 2024. Interviews with the Unit Manager and Director of Nurses confirmed that the required monitoring was not performed for these residents.
Failure to Offer Pneumococcal Conjugate Vaccine
Penalty
Summary
The facility failed to offer the Pneumococcal Conjugate Vaccine (PCV) to a resident at the time of admission or shortly thereafter, as required by their policy. Specifically, Resident #28, who was admitted in June 2023 with diagnoses including generalized anxiety disorder, major depressive disorder, insomnia, alcohol abuse, and HIV, was not offered the PCV despite having no medical contraindications. The Massachusetts Immunization Information System (MIIS) Vaccine Administration Record indicated that the resident had no history of receiving the PCV, and there was no documentation in the resident's medical record that the vaccine had been offered, received, or declined. This oversight put the resident at risk for developing facility-acquired pneumonia. During an interview, the Infection Preventionist (IP) acknowledged that the resident should have been offered the vaccine but had not been, and admitted that a system for tracking Pneumococcal vaccinations had not yet been developed. The facility's policy, dated January 2024, mandates that all eligible residents be offered the Influenza and Pneumococcal vaccines unless medically contraindicated. The policy also specifies that adults aged 19-64 with certain underlying medical conditions or other risk factors should receive one dose of PCV if they have not previously received it or if their vaccination status is unknown. Despite these guidelines, the facility failed to adhere to its own policy in the case of Resident #28. The IP confirmed that the process involves taking information from MIIS and adding it to the facility's electronic health record (EHR), and that every new admission should be offered a consent for Pneumococcal immunization. However, this process was not followed for Resident #28, leading to the deficiency noted in the report.
Failure to Maintain Functioning Call System
Penalty
Summary
The facility failed to maintain a functioning call system that would allow residents to directly contact caregivers. Specifically, the call bell system in five resident rooms on Unit Two was not working, and the facility did not provide an alternative communication method for Resident #119. The issue was identified during an interview with the Ombudsman, who stated that the call light system had not worked since January 2024. The surveyor confirmed the malfunction during the initial screening process and observed that the call system was not functioning in the specified rooms. Resident #119, who was cognitively intact with a BIMS score of 15 out of 15, reported that their call bell had not been working for several weeks and that they were not provided with a hand bell as an alternative. The surveyor observed that the call bell in Resident #119's room did not work and that no hand bell was present. The Maintenance Director acknowledged that the call bell system had been malfunctioning for a couple of months and that repairs were ongoing. However, the necessary batteries and light bulbs for the repairs had not yet arrived, and Resident #119 had not been provided with a hand bell as required by the facility's policy.
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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