Regalcare At Quincy
Inspection history, citations, penalties and survey trends for this long-term care facility in Quincy, Massachusetts.
- Location
- 211 Franklin Street, Quincy, Massachusetts 02169
- CMS Provider Number
- 225522
- Inspections on file
- 20
- Latest survey
- April 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Regalcare At Quincy during CMS and state inspections, most recent first.
Four residents with cognitive and physical impairments were repeatedly observed with their call lights out of reach, either on the floor or draped over nightstands, making them unable to call for staff assistance. Staff interviews confirmed that call lights should have been accessible at all times, but this was not maintained according to facility policy.
The facility did not ensure residents were aware of or had access to the grievance process, as several residents reported not seeing postings or knowing how to file grievances except by telling staff. Grievance forms were not readily available on all units, and there was no clear method for anonymous submission, with the social worker confirming these deficiencies during a facility tour.
The facility did not develop or implement individualized care plans for several residents, including those with pain management needs, antipsychotic medication use, fall risk, and oxygen therapy. Care plans were incomplete, generic, or missing, and staff failed to document required assessments and interventions, resulting in deficiencies in meeting residents' specific care needs.
Two residents with severe cognitive impairment were exposed to accident hazards when a wound treatment cart containing medications was left unlocked and unattended in a common area, allowing one resident to rummage through its contents, and when a freestanding oxygen cylinder was repeatedly observed unsecured in a resident's room near the bed. Staff interviews confirmed that these practices did not follow facility policy or safety standards.
A resident with severe cognitive impairment and a PICC line for IV antibiotics did not receive care consistent with professional standards, as staff failed to document dressing changes, measure and record external catheter length, and assess arm circumference. After the resident pulled out the PICC line, there was no documentation of the total catheter length to confirm it was intact, and staff were unclear on protocols and documentation requirements.
Medication carts, medication rooms, and an OTC medication room were found unlocked and unattended, allowing potential access to drugs and biologicals by unauthorized individuals. Staff acknowledged that these areas should have been locked, and several residents with Alzheimer's disease or dementia resided on the affected units, increasing the risk of unauthorized access.
The facility did not ensure that meals were served at palatable and safe temperatures, as required by policy. Multiple residents reported receiving cold meals, and test trays on two units showed that hot foods were served below the required temperature and cold foods above the required temperature. Dietary staff and the FSD confirmed the temperature issues and attributed them to a malfunctioning plate warmer that had not been replaced.
Surveyors found that the facility did not properly label or date food items, allowed staff food in the main kitchen, and stored milk cartons on the floor. In a kitchenette, several food and drink items were undated or stored in broken containers, with some showing visible spoilage. Black mold-like residue was observed on kitchen surfaces, and staff were seen preparing food without required hair restraints.
The facility failed to maintain an effective infection control program, with incomplete infection surveillance records, unsecured treatment carts accessed by a resident without hand hygiene, and an oxygen concentrator filter used by a resident with COPD that was visibly dirty and not cleaned as required. Staff did not intervene when the resident accessed the carts, and documentation for infection surveillance was missing key information.
Staff did not create a baseline or comprehensive care plan within 48 hours of admission for a resident with PTSD and on antipsychotic medication, as required by facility policy. Although staff were aware of the resident's diagnoses and medication orders, no care plan was developed to address these needs, and this was confirmed by both the social worker and unit manager during interviews.
Surveyors found that two residents did not receive care consistent with professional standards: one resident did not have compression stockings applied as ordered, with no documentation to explain the omission, and another had an incomplete healthcare proxy invocation form, missing required details about incapacity. Staff interviews confirmed lapses in following and documenting physician orders and regulatory requirements.
A resident with PTSD, anxiety, and depression was not assessed for trauma history or potential triggers, and no individualized care plan was developed to address these needs. Staff, including the Director of Social Services, acknowledged the oversight, and documentation lacked details or interventions to prevent re-traumatization, contrary to facility policy.
A resident with a recent upper extremity fracture was provided a bed rail without an assessment for safety risks, review of risks and benefits, or informed consent. The facility's policy requiring interdisciplinary assessment, physician consultation, and documentation was not followed, and no care plan or physician order for the bed rail was found.
The facility failed to ensure that monthly pharmacist medication regimen review recommendations were addressed and documented for two residents, including one with COPD who did not have proper inhaler instructions added, and another receiving Seroquel without timely clarification or rationale for continued use. Staff interviews confirmed that the process for completing and recording these recommendations was not consistently followed.
The facility did not maintain complete and accurate medical records for two residents: one resident's healthcare proxy activation form was missing required information about incapacity, and another resident's administration of Tramadol was not consistently documented on the MAR, despite evidence from the narcotic count book. Staff interviews confirmed that these omissions resulted in incomplete and inaccurate records.
Essential kitchen equipment, including a microwave, food processor, and plate warmer, were not maintained in safe working order. A microwave in a resident kitchenette had a non-functional door button for about a week, the main kitchen's food processor was inoperable for several months unless bypassed with a magnet, and one column of the plate warmer was not working, requiring staff to rotate and cover plates to keep them warm. These issues were known to staff and had been reported but not addressed.
The facility failed to maintain sanitary conditions in two resident kitchenettes. Observations revealed mouse droppings, dried liquid stains, and food remnants in cabinets and on floors. The microwave was found with food remnants and soiled paper towels. Housekeeping admitted to inadequate cleaning practices, and the Corporate Consultant confirmed the need for thorough cleaning inside cabinets and microwaves.
A facility failed to label an opened Lantus insulin vial with the date opened and expiration date, as required by policy. This was observed during a surveyor's review of a medication cart. Nurse #1 and the DON confirmed the labeling requirement, noting the insulin's 28-day expiration period.
A resident with serious health conditions, including lung cancer and COPD, had an abnormal chest X-ray that was not communicated to the physician or nurse practitioner. The facility's policy required prompt notification of abnormal test results, but documentation showed no evidence of communication. Interviews revealed a breakdown in communication and documentation processes, with the Director of Nursing confirming the lack of notification.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that four residents had their call bell devices accessible and within reach while in their rooms, as required by facility policy. The policy specifies that call lights must be plugged in at all times and within easy reach of residents when they are in bed or confined to a chair. Multiple observations by the surveyor revealed that the call lights for these residents were consistently found on the floor or draped over the far side of nightstands, making them inaccessible to the residents. The residents involved had varying degrees of cognitive impairment and physical limitations, including histories of falls, dementia, pelvic fracture, chronic pain, and adult failure to thrive. Some residents were unable to locate their call lights or did not respond when asked about them, while others stated they could not find or reach their call lights. In several instances, the call lights were observed out of reach during multiple checks throughout the day, regardless of whether the residents were awake or asleep. Interviews with staff, including CNAs, nurses, the ADON, and the DON, confirmed that all residents should have access to their call lights, regardless of their ability to use them. Staff acknowledged that the call lights were not within reach and that this was not in accordance with facility policy. The deficiency was identified through repeated observations and staff interviews, which consistently demonstrated a lack of compliance with the requirement to keep call lights accessible to residents.
Failure to Ensure Resident Awareness and Access to Grievance Process
Penalty
Summary
The facility failed to ensure that residents were fully informed about the grievance process, as required by its own policy. During a resident group meeting attended by 10 residents from both facility units, several residents reported not having seen any postings about the grievance process and were unaware of how to file a grievance except by informing a staff member. Residents indicated that grievance forms were not readily accessible, and there was confusion about the ability to file grievances anonymously. One resident mentioned possibly seeing forms near the elevator but was unsure, and did not know who the grievance officer was. The majority of residents present agreed with these statements. Observations during tours of the facility revealed a lack of postings about the grievance process and limited access to grievance forms. On the second-floor unit, grievance forms were found only in a wall-mounted holder outside the social worker's office, which was not easily accessible to all residents, and there were no instructions for anonymous submission. The third-floor unit had no postings or available grievance forms, and an empty folder labeled grievances was found at the nursing station. The social worker acknowledged the absence of necessary postings and forms, and stated that the process for anonymous grievance submission had not been considered.
Failure to Develop and Implement Individualized Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, implement, and individualize comprehensive care plans for five residents, resulting in deficiencies in meeting their specific care needs. For one resident with spinal stenosis and recent back surgery, the care plan for pain management was incomplete and not individualized, with many blank areas and lacking resident-specific information. Nursing staff did not consistently document pre- and post-medication pain assessments or the effectiveness of PRN pain medication, despite the resident receiving multiple doses. The medication administration record was not properly updated, and the effectiveness of pain interventions was not monitored as required by the care plan and facility policy. Two residents receiving antipsychotic medication (Seroquel) did not have care plans that identified the targeted behaviors, specific interventions, or measurable goals for the use of these medications. In both cases, staff and family interviews indicated that the residents did not exhibit the behaviors typically associated with the use of antipsychotics, and the care plans failed to include non-pharmacological interventions or rationale for the medication. The care plans were generic and did not reflect the residents' actual needs or conditions, and one resident's use of antipsychotic medication was not care planned at all. Additionally, after a resident sustained a fall, the facility did not implement or document any new interventions to minimize future falls, contrary to facility policy. Another resident using continuous oxygen therapy did not have a care plan addressing oxygen use, despite physician orders and the resident's significant cognitive impairment and respiratory needs. In each case, the lack of individualized, comprehensive care planning and failure to implement or document required interventions led to deficiencies in the facility's care delivery process.
Unsecured Treatment Cart and Improper Oxygen Cylinder Storage
Penalty
Summary
The facility failed to ensure that two residents were free from accident hazards due to lapses in supervision and improper storage of potentially harmful items. For one resident with severe cognitive impairment and moderate dementia, a wound treatment cart containing various topical medications and antiseptics was observed unlocked and unattended in a common area near the resident. The resident was seen rummaging through the cart multiple times, opening several drawers, while staff in the vicinity either did not intervene or failed to secure the cart. Interviews with nursing staff revealed they were unaware the cart was unlocked and did not have keys to lock it, despite facility policy requiring all medication storage areas to be locked when unattended. Another resident, also with significant cognitive impairment and a diagnosis of chronic obstructive pulmonary disease, had a freestanding oxygen cylinder (E-Tank) stored unsecured next to their nightstand and near their roommate's bed. The E-Tank was observed on multiple occasions over two days in the same unsecured position. Staff interviews confirmed that oxygen cylinders should not be left in resident rooms when not in use and, if present, must be secured in a cylinder stand or to a wheelchair. The E-Tank was neither secured nor properly stored according to facility policy and national fire safety codes. These deficiencies were confirmed through direct observation by surveyors and corroborated by staff interviews, which acknowledged the lapses in following established safety protocols for medication and oxygen storage. The facility's own policies and national safety standards were not adhered to, resulting in residents having access to accident hazards.
Failure to Maintain and Document PICC Line Care and Monitoring
Penalty
Summary
The facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC) consistent with professional standards of practice for one resident. The facility did not ensure documentation of PICC line dressing changes, did not measure and document the external catheter length to monitor for migration, did not measure and document arm circumference, and did not measure and document the total catheter length when the PICC line was pulled out by the resident. The facility's policy required these actions to prevent complications such as infection and catheter migration, but these were not followed or documented in the resident's medical record. The resident involved had severe cognitive impairment and was receiving IV antibiotics for sepsis through a PICC line. Upon observation, the resident was found with a PICC line in place but without a transparent dressing, and a loosely wrapped gauze was present instead. The resident was observed touching and playing with the PICC line. Nursing staff stated that a dressing change had been performed the previous day, but there was no documentation of this, nor of the required measurements of external catheter length or arm circumference. Additionally, after the resident pulled out the PICC line, there was no documentation of the total catheter length to confirm the catheter was intact, as required by policy and manufacturer guidelines. Interviews with nursing staff and facility leadership revealed a lack of clear orders for PICC line dressing changes and required measurements. Staff were unsure of the protocol for dressing changes and did not consistently document required information. The Medication Administration Record and Treatment Administration Record did not have designated areas for documenting these measurements. The absence of documentation and adherence to policy was acknowledged by staff and leadership during the survey.
Failure to Secure Medication Storage Areas
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in accordance with professional standards and its own policies. On one unit, a medication cart was observed unlocked and unattended in a hallway, with staff and others passing by. The nurse responsible for the cart acknowledged that it should have been locked but stated she was distracted and forgot to secure it. Additionally, both the 2nd and 3rd floor medication rooms were found unlocked and unattended at various times, with no licensed staff in the immediate vicinity. In one instance, a nurse was able to open the medication room door without a key, confirming it was not properly secured. The facility's policy requires all medication storage areas, including carts and rooms, to be locked when not in use or under direct supervision. The survey also found that the over-the-counter (OTC) medication room on one unit was unlocked and accessible, with shelves of medications available to anyone passing by. Nurses and the Director of Nursing confirmed that these areas should have been locked at all times when unattended. The report notes that several residents on the affected units had diagnoses of Alzheimer's disease or dementia, increasing the potential for residents to access and ingest medications if storage areas are not properly secured.
Failure to Serve Palatable Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve meals that were palatable and at appetizing temperatures on two units, as evidenced by observations, interviews, and meal test tray results. According to the facility's policy, hot foods should be maintained at or above 135°F and cold foods at or below 41°F. During a Resident Council Meeting, half of the participating residents reported that breakfast and lunch were often served cold and that there were not enough staff to pass trays. Test trays conducted on both the Second and Third Floor Units revealed that several hot food items, such as scrambled eggs, waffles, and sausage, were served at temperatures below the required threshold and were described as lukewarm or cold and lacking flavor. Cold items, such as milk and orange juice, were also served above the required cold temperature, with some items being lukewarm to taste. Interviews with dietary staff and the Food Service Director (FSD) confirmed that the food temperatures were not within the appropriate ranges and did not meet expectations for palatability. The FSD acknowledged that one column of the plate warmer had not been working for some time, requiring staff to rotate hot plates and cover them with a pot as a workaround. The FSD stated that the kitchen needed a new plate warmer and that all staff were aware of the issue. These actions and inactions led to the deficiency in serving meals at safe and appetizing temperatures.
Failure to Maintain Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, as evidenced by multiple observations in both the main kitchen and a kitchenette. Surveyors found that food items in the main kitchen walk-in refrigerator were not properly labeled or dated, including an opened container of thickened cranberry juice and a pouch of whipped cream, both lacking required date markings. Additionally, milk cartons were stored directly on the floor, and staff members' personal food and beverages were found in the main kitchen refrigerator, contrary to facility expectations. The Food Service Director (FSD) confirmed that all foods should be labeled with the date opened and use-by date, and that staff food should be stored in the employee break room, not the main kitchen. In the third-floor kitchenette, surveyors observed several food and drink items that were not properly labeled or dated, including open containers of nutritional drinks and dairy-free milk, as well as resident-provided foods that were undated or stored in broken containers. Some items were found with visible spoilage, such as a container with a black fuzzy substance under the cover. The FSD stated that foods from home should be labeled with the resident's name and date brought in, and that expired or spoiled foods should be discarded. Despite these expectations, the surveyor repeatedly found improperly stored and labeled items during multiple visits. Sanitation issues were also identified in both the main kitchen and the kitchenette. The wall behind the dishwashing station in the main kitchen and the countertop next to the sink in the kitchenette were observed on several occasions to have black mold-like residue. The FSD and other staff acknowledged the presence of this residue and attributed it to moisture and water splashing, but it was not adequately addressed. Additionally, staff were observed preparing and serving food without appropriate hair restraints, and the hair net holder in the kitchen was empty. The FSD confirmed that staff should not be near food preparation areas without proper hair or beard covers.
Infection Control Program Deficiencies: Incomplete Surveillance, Unsecured Treatment Carts, and Unclean Oxygen Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete and inaccurate infection surveillance documentation, unsecured treatment carts accessible to residents, and unclean oxygen concentrator filters. The Infection Preventionist (IP) did not ensure that infection surveillance line listings for multiple months included all required information, such as complete symptom listings, culture site and results, and infection clearance status for healthcare-associated infections (HAIs) like skin infections, urinary tract infections (UTIs), and pneumonia. The IP acknowledged that the line listings should be complete and that missing information was not acceptable. Treatment carts on the third floor were repeatedly observed to be left unlocked and unattended, allowing a resident to open drawers and touch items inside without performing hand hygiene. Both housekeeping and CNA staff witnessed the resident accessing the carts but did not intervene or alert nursing staff. The ADON/IP confirmed that treatment carts should always be locked and that residents should not have access to their contents, as this constitutes a breach of infection control protocols and compromises the items inside the carts. Additionally, a resident with chronic obstructive pulmonary disease (COPD) was observed using an oxygen concentrator with a filter that was caked with dust and debris over multiple days. Although there was a physician's order to clean the filter weekly, the filter was visibly dirty, and staff could not confirm when it was last cleaned. The DON stated that oxygen equipment should be clean and follow infection control protocols, but the lack of regular cleaning and documentation led to the deficiency.
Failure to Develop Baseline Care Plan for Resident with PTSD and Antipsychotic Use
Penalty
Summary
Staff failed to develop a baseline or comprehensive care plan within 48 hours of admission for a resident with multiple diagnoses, including PTSD, anxiety, depression, and a recent fracture. The facility's policy requires that a baseline care plan be created within 48 hours to address immediate needs, including initial goals, physician's orders, dietary needs, therapy, social services, and PASARR recommendations. However, review of the resident's records showed that no care plan was developed within the required timeframe to address the resident's PTSD diagnosis or the use of the antipsychotic medication Quetiapine (Seroquel). Interviews with facility staff confirmed awareness of the resident's PTSD diagnosis and antipsychotic medication order, but acknowledged that a care plan addressing these needs was not created as required. The social worker stated she was aware of the PTSD diagnosis but did not know the resident's trauma history or triggers and admitted that a care plan should have been developed but was not. The unit manager also confirmed that no baseline or comprehensive care plan was found in the resident's record to address the use of antipsychotic medication.
Failure to Apply Compression Stockings and Incomplete Healthcare Proxy Invocation
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for two residents. For one resident with chronic kidney disease, congestive heart failure, and dementia, there was a physician's order for daily application of compression stockings to both lower extremities. Despite this order, multiple observations over two days showed the resident did not have compression stockings applied, and their lower extremities were swollen and discolored. The Medication Administration Record (MAR) indicated the stockings were applied as ordered, but there was no documentation in the medical record to support that the order was on hold, discontinued, or that the resident refused the intervention. Nursing staff were unclear about their responsibility to check for the application of compression stockings throughout the day, and facility leadership confirmed that documentation should be present if the order was not followed. For another resident with dementia and severe cognitive impairment, the healthcare proxy (HCP) was invoked by a nurse practitioner due to cognitive decline. The HCP invocation form, however, was incomplete; specifically, the sections for the cause and nature of the incapacity were left blank, although the extent and probable duration were documented. The nurse practitioner acknowledged the error and stated that completing the cause and nature is standard practice. Facility leadership also confirmed that the HCP invocation form should be fully completed in accordance with regulatory requirements. These deficiencies were identified through observation, interview, and record review, and were found to be inconsistent with professional standards of quality and regulatory requirements as outlined by the Massachusetts Board of Registration in Nursing and state law regarding healthcare proxy activation.
Failure to Assess and Plan Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to assess and address the trauma history and related care needs of a resident with a documented diagnosis of PTSD, anxiety, and depression. Despite the facility's policy requiring trauma assessments and individualized care planning, there was no evidence in the medical record that staff collaborated with the resident or other healthcare professionals to identify the nature of the trauma, its effects, or potential triggers. The psychiatric nurse practitioner's documentation acknowledged the PTSD diagnosis but did not provide details about the trauma or interventions to mitigate re-traumatization. Interviews with the resident confirmed a history of significant trauma in both childhood and adulthood. The Director of Social Services admitted to missing the trauma assessment and care plan for this resident, despite being aware of the PTSD diagnosis. Additionally, the Unit Manager and Regional Nurse were unable to identify the nature of the resident's trauma or any specific triggers, indicating a lack of comprehensive assessment and person-centered planning as required by facility policy.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess a resident for the use of a bed rail, as required by its own policy and regulatory standards. Specifically, the facility did not conduct an assessment to identify the reason for using the side rail or evaluate the risk of entrapment. There was no evidence of an interdisciplinary assessment, consultation with a physician or nurse practitioner, or input from the resident or their legal representative regarding the benefits and potential hazards associated with side rail use. Additionally, the facility did not obtain informed consent from the resident or their representative prior to the installation of the bed rail. The deficiency was identified for a resident who was admitted following a left proximal humerus fracture after a fall at home. The resident was cognitively intact but had functional limitations in the upper and lower extremity on one side. Observations showed a bed rail attached to the left side of the resident's bed, which the resident could not use for repositioning due to pain and limited mobility. Review of the medical record revealed no physician's order, no care plan, and no signed consent for the use of the bed rail, despite the facility's policy requiring these steps.
Failure to Address and Document Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the consultant pharmacist were addressed in a timely manner and maintained as part of the permanent medical record for two residents. For one resident with chronic obstructive pulmonary disease (COPD), the consultant pharmacist recommended that instructions be added to the physician's order for Trelegy Ellipta inhaler to rinse the mouth after use to prevent oral thrush. This recommendation, made in February, was not addressed by the physician, and there was no documentation in the medical record indicating that the recommendation had been acted upon. For another resident with dementia and anxiety, who had been receiving Seroquel since admission, the consultant pharmacist made multiple recommendations over several months. These included requests for a psychiatric consult to review the appropriateness of Seroquel, consideration of a gradual dose reduction, and clarification or update of the diagnosis associated with the medication. The responses to these recommendations were either incomplete, lacking a rationale for continued use, or not documented at all. The diagnosis for Seroquel was eventually changed from sleep to depression, but there was no documentation in the medical record to indicate that the pharmacist's recommendations from August or January had been addressed. Interviews with facility staff confirmed that the process for addressing and documenting MRR recommendations was not consistently followed. The Unit Manager and DON acknowledged that recommendations were not always completed or uploaded into the electronic medical record as required, and the consultant pharmacist reported that his recommendations were not routinely addressed or documented by his next visit, as expected by facility policy.
Incomplete Medical Records and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident with dementia and severe cognitive impairment, the healthcare proxy (HCP) activation form was not fully completed. Specifically, the section requiring documentation of the cause and nature of the resident's incapacity was left blank by the nurse practitioner who invoked the HCP. Both the Director of Nursing (DON) and the Administrator confirmed that the form was incomplete, making the medical record inaccurate for this resident. For another resident admitted with spinal stenosis and post-laminectomy, the administration of Tramadol, a pain medication, was not consistently documented on the Medication Administration Record (MAR). Although the narcotic count book showed that 13 doses of Tramadol were dispensed over several days, these administrations were not recorded on the MAR. The nurse responsible acknowledged that she had administered the medication but failed to document it as required. Interviews with facility staff, including the DON and the Administrator, confirmed that the expectation is for all medication administrations and relevant medical information to be accurately and completely documented in the residents' medical records. The lack of documentation resulted in incomplete and potentially inaccurate records for both residents involved.
Failure to Maintain Kitchen Equipment in Safe Working Order
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe working order, as evidenced by multiple observations and staff interviews. On two separate occasions, a microwave in the third-floor resident kitchenette was found to have a non-functional door open button, preventing its use. The Food Service Director (FSD) confirmed that the microwave had been broken for about a week and that maintenance had been notified, but no repairs had been made. The microwave was used by residents to heat their own food or to have staff heat food for them, and the facility's policy required all kitchen equipment to be kept functional. Additionally, the main kitchen's food processor, used to puree food for residents, was demonstrated to be inoperable unless a magnet was used to bypass a safety feature. Staff reported that the food processor had been broken for six months to a year and that it had been reported to both the FSD and maintenance, but it remained unfixed. Furthermore, one column of the plate warmer in the main kitchen was not working, requiring staff to rotate plates and cover them with a pot to keep them warm. The FSD stated that the plate warmer had not been working for some time, and the need for a replacement was known among staff.
Failure to Maintain Sanitary Conditions in Resident Kitchenettes
Penalty
Summary
The facility failed to maintain two resident nourishment kitchenettes in a clean and sanitary condition, as observed by the surveyor. On the Third-floor kitchenette, there were mouse droppings and dried liquid stains around a metal pest trap under the sink, and additional stains and food remnants were found in the cabinets. A sticky dried liquid stain was also noted on the floor in front of the refrigerator. On the Second-floor kitchenette, the microwave was found with food remnants and heavily soiled paper towels, and the floor was tacky with visible food remnants. A large food stain was also present on the wall and floor near the radiator. During interviews, Housekeeper #1 admitted to only wiping down the outside of the microwave and acknowledged the need for better cleaning practices, including the inside of the microwave and the floor. The Corporate Consultant confirmed that housekeeping should be responsible for cleaning inside the cabinets and microwaves and ensuring the floors are clean and free from food. Despite the facility's policy requiring regular cleaning, these observations indicated a failure to adhere to the established standards for maintaining sanitary conditions in the kitchenettes.
Failure to Properly Label Insulin Vials
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly labeled in accordance with currently accepted professional principles. Specifically, the deficiency was observed in one of the three medication carts reviewed, where an opened multiple dose injection vial of Lantus (insulin glargine) was found without a label indicating the date it was opened or its expiration date. This oversight was noted during a surveyor's review of the 3rd floor unit main side medication cart. During interviews, Nurse #1 acknowledged that the insulin packaging box and vial should have been labeled with the open date and expiration date, as the insulin has a shortened expiration period of 28 days. The Director of Nurses (DON) confirmed that staff are required to label medications, including insulin, with the date opened and expiration date to ensure they are removed and replaced once expired. The failure to label the insulin vial and packaging correctly was a deviation from the facility's policy on medication storage.
Failure to Notify Physician of Abnormal X-ray Results
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of an abnormal chest X-ray for a resident who was admitted with multiple serious health conditions, including metastatic squamous cell carcinoma of the larynx, primary lung cancer, pneumonia, and chronic obstructive pulmonary disease (COPD). The resident had a history of acute hypoxic respiratory failure and pleural effusion requiring drain placements. A stat chest X-ray was ordered on March 9, 2024, due to the resident's respiratory distress, but the results indicating significant abnormalities were not communicated to the medical team. The facility's policy required that nursing staff promptly notify the attending physician of any abnormal test results, especially when the resident's clinical status is unstable. However, the documentation review revealed that the X-ray results, which showed near-complete opacification of the left lung and other concerning findings, were not communicated to the physician or nurse practitioner. The Director of Nursing (DON) confirmed that there was no documentation in the electronic medical record indicating that the medical team was informed of the X-ray results. Interviews with nursing staff and the DON indicated a breakdown in communication and documentation processes. The nurse who ordered the X-ray left the responsibility of following up on the results to the next shift, but the results were not communicated. The DON and nurse practitioner confirmed that there was no record of the X-ray results being shared with the medical team, and the secure electronic system used for communication automatically deleted older messages, further complicating the situation.
Latest citations in Massachusetts
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
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