Twin Oaks Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Danvers, Massachusetts.
- Location
- 63 Locust Street, Danvers, Massachusetts 01923
- CMS Provider Number
- 225198
- Inspections on file
- 16
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Twin Oaks Center during CMS and state inspections, most recent first.
The facility failed to ensure staff received required dementia training and did not implement an effective Infection Prevention and Control Program or Antibiotic Stewardship Program. Administrative leadership was unaware of missing training documentation and did not address clinical concerns in QAPI meetings, while the President of Operations was not informed about the lack of QAPI activities. These failures resulted in deficiencies related to staff competency, infection control, and quality assurance.
The facility's governing body did not provide oversight or accountability for the QAPI and infection control/antibiotic stewardship programs, as evidenced by the absence of documentation, lack of program implementation for several months, and unawareness among leadership regarding program status and responsibilities.
The facility did not maintain a comprehensive, data-driven QAPI program for an extended period following a change in ownership, resulting in the absence of key quality initiatives such as Infection Control and Antibiotic Stewardship. Multiple new staff members were hired without required training, registry checks, or health screenings, and there was no evidence of infection monitoring or reporting to the QAPI committee during this time.
The facility did not ensure its QAPI Committee met as required or addressed quality deficiencies, as the program was not implemented for several months following a change in ownership. During this period, there was also no active Infection Control Program, and essential monitoring and data collection activities were not conducted.
The facility did not implement or maintain an infection prevention and control program, failing to track, monitor, or document infections and outbreaks among residents and staff. Despite multiple antibiotic prescriptions for various infections, there was no evidence of surveillance activities, line listings, or reporting data. The DON, IP, and Administrator were unaware of infection rates or trends, and the Medical Director confirmed the absence of an infection control program.
The facility did not implement or document an Antibiotic Stewardship Program, failing to track, monitor, or review antibiotic use for residents over an extended period. Leadership, including the DON, Infection Preventionist, Administrator, and Medical Director, confirmed the absence of infection surveillance, data collection, and program activities as required by facility policy.
Surveyors found that a medication cart was left unlocked and unattended, allowing unauthorized access to medications. Medications on a cart were not properly labeled or dated when opened, and a medication refrigerator lacked a working thermometer and complete temperature logs, resulting in improper storage conditions for temperature-sensitive drugs. Nursing staff and leadership confirmed these practices did not meet facility policy or manufacturer guidelines.
Staff on one unit failed to provide a dignified dining experience by referring to a resident as a 'feeder' instead of using their name. Both a CNA and a nurse used this term in the dining room, and neither was corrected at the time. Facility policy requires residents to be addressed by name, and leadership confirmed that referring to residents as 'feeders' is not acceptable.
The facility did not timely report two separate incidents involving a resident who suffered a head laceration requiring staples and a right femoral neck fracture requiring surgery. Both events were not reported to the state agency as required by facility policy and regulations, with one incident not reported at all and the other reported ten days late. Interviews with the DON and Administrator confirmed awareness of the incidents and the reporting failures.
A resident with schizophrenia, intellectual disability, and PTSD, who exhibited chronic paranoia and delusions, did not have these behavioral health needs addressed in their care plan. Despite documentation and staff awareness of the resident's specific fears and behaviors, the care plan lacked person-centered interventions as required by facility policy.
Two residents did not receive care in accordance with physician orders: one was administered oxygen without a documented order specifying flow rate or tubing change frequency, and another received enteral feeding with the wrong formula and rate. Nursing staff and leadership confirmed the lack of required orders and failure to follow prescribed instructions.
A resident with peripheral vascular disease and cognitive impairment was observed with a soiled, partially exposed wound dressing on the right ankle that had not been changed for three days, despite physician orders and nursing documentation indicating daily changes. Nursing staff and the DON confirmed that daily dressing changes were expected, but direct observation revealed the deficiency.
A resident with severe cognitive impairment and a contracture in the left hand did not consistently receive a physician-ordered rolled washcloth to the contracted hand every shift. Despite documentation indicating the intervention was completed, multiple observations found the facecloth was not in place, and staff could not provide a documented reason for the omission.
A resident with moderate cognitive impairment and multiple diagnoses experienced significant unmonitored weight loss over several months. Facility staff failed to consistently document weights, perform reweighs, or notify the physician and dietitian as required. Dietary interventions were inconsistently applied, and staff interviews revealed a lack of awareness and follow-up regarding the resident's nutritional status.
Two residents with PTSD and significant trauma histories did not have person-centered care plans addressing their trauma, triggers, or history of suicide attempt. Despite documented histories of abuse, violence, and psychiatric diagnoses, the facility's assessments and care plans failed to identify or address these needs, as confirmed by staff interviews.
A nurse administered medications incorrectly to a resident by giving Lactase tablets after a meal instead of before, and by delivering two sprays of saline nasal solution per nostril instead of the ordered one spray. These actions resulted in a medication error rate of 6.06%, exceeding the regulatory limit of 5%.
A resident with impaired cognition and a history of peripheral vascular disease was repeatedly observed with a soiled, unchanged dressing on an open ankle wound, despite nursing documentation in the MAR indicating daily dressing changes. Nursing staff confirmed the dressing had not been changed as recorded, and the DON could not provide a policy on accurate documentation.
A resident was not offered the Influenza vaccine during influenza season, contrary to facility policy. Record review and staff interviews revealed that vaccination tracking was not being performed, and there was confusion among the DON, Infection Preventionist, and Administrator regarding responsibility for the vaccination program.
A resident was not offered the COVID-19 vaccine upon admission or during their stay, as required by facility policy. Record review confirmed the resident remained unvaccinated, and interviews with the DON, Infection Preventionist, Administrator, and Medical Director revealed a lack of tracking and unclear responsibility for the vaccination program.
A resident with cognitive decline and other health issues was hospitalized due to dehydration, acute kidney injury, and hypernatremia after the facility failed to provide adequate hydration. Despite elevated lab results indicating dehydration, the facility did not initiate a hydration protocol or address the lab values promptly, resulting in a delay in treatment.
A resident with severe cognitive impairment and multiple diagnoses had critically high sodium levels that were not promptly communicated to the physician or NP, resulting in a delay in treatment. The resident was eventually sent to the hospital for hypernatremia, dehydration, and acute kidney injury. The Medical Director noted that immediate notification was expected for such critical lab values.
The facility failed to assess hydration status and obtain consent before administering IV hydration to three residents, and did not conduct a required Depakote level test for another resident. Medical records lacked documentation of hydration assessments and consents, and interviews revealed inconsistencies in the consent process.
Deficient Administrative Oversight in Staff Training, Infection Control, and QAPI
Penalty
Summary
The facility failed to provide appropriate administrative oversight to ensure effective use of resources and to attain the highest practicable well-being of each resident. Specifically, the administration did not ensure that pre-employment health requirements and dementia training were provided to all staff, as evidenced by 3 out of 5 new hire employee records lacking proof of dementia training. Additionally, there was a lack of orientation and education for staff on policies and procedures related to dementia care. The administration also failed to implement and maintain an Infection Prevention and Control Program (IPCP), including the absence of an Antibiotic Stewardship Program for monitoring, tracking, and improving antibiotic use and infection control measures. Interviews revealed that the Administrator was unaware of the missing dementia training documentation and could not provide evidence that clinical concerns, such as infection control and antibiotic stewardship, were discussed in QAPI meetings. The Medical Director confirmed the absence of an Infection Control Program and stated that infection monitoring, data collection, and reporting were not in place. Furthermore, the President of Operations was not informed about the lack of QAPI activities for several months and did not review QAPI minutes to ensure compliance. These failures resulted in deficiencies cited under F837, F880, and F881.
Lack of Governing Body Oversight for QAPI and Infection Control Programs
Penalty
Summary
The facility failed to ensure that its governing body provided oversight and accountability for the maintenance of an effective Quality Assurance and Performance Improvement (QAPI) program and the provision of an infection control/antibiotic stewardship program. Review of facility policy indicated that the Administrator is responsible and accountable to the governing body for QAPI implementation, and that QAPI activities should be a standing agenda item for governing body meetings. However, during the survey, the facility was unable to provide documentation related to infection tracking, reporting data, or antibiotic stewardship, and there was no evidence that QAPI had been initiated for these programs. Interviews revealed that the QAPI program had not been implemented from the time of ownership change in June 2024 until February 2025, with no meeting minutes or projects available for that period. The Administrator was unaware that infection control and antibiotic stewardship programs were not being implemented and had not informed the governing body of the lack of QAPI prior to February. Additionally, the President of Operations/owner was not aware of who the governing body representative was for the facility and was not informed about the absence of QAPI activities during the specified period.
Failure to Implement and Maintain Comprehensive QAPI Program
Penalty
Summary
The facility failed to implement and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, as required. Although a QAPI policy was in place, review of records and staff interviews revealed that the program was not operational from June 2024 until February 2025 following a change in ownership. During this period, there were no QAPI meeting minutes or documented projects, and key quality programs such as Infection Control and Antibiotic Stewardship were not being implemented. The Administrator and Director of Nursing both confirmed that these programs were not in place prior to their recent arrival and that the QAPI program had only recently been re-initiated. Further review of new employee records showed multiple deficiencies in staff onboarding and compliance with regulatory requirements. Several new hires lacked required dementia training, CNA registry checks, preemployment physicals, tuberculin testing, and documentation of COVID vaccination or declination. The Director of Nursing's license was not checked prior to employment. The Medical Director also confirmed the absence of an Infection Control Program and stated that infection monitoring, antibiotic stewardship, and vaccination tracking were not being conducted or reported to the QAPI committee. These findings demonstrate a lack of comprehensive, data-driven quality assurance processes and oversight during the identified period.
Failure to Implement and Maintain QAPI Committee and Infection Control Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) Committee met as required and addressed quality deficiencies through the development and implementation of corrective action plans. According to the facility's own QAPI policy, the committee was supposed to meet monthly and include representatives from key departments to monitor, assess, and improve care and operations. However, the Administrator confirmed that the QAPI program was not implemented from June 2024 until February 2025 following a change in ownership, and no QAPI meeting minutes or projects could be found for that period. Additionally, the Medical Director, who began in April 2025, stated that there was no Infection Control Program in place and that infection monitoring, tracking, and data collection were not occurring as expected. The lack of an active QAPI committee and absence of infection control oversight meant that quality gaps, including those related to infection prevention and antibiotic stewardship, were not being systematically identified or addressed during the specified timeframe.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as required, resulting in the absence of a system for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. Despite having a policy that outlines the responsibilities of the Infection Preventionist (IP) and nursing staff for ongoing surveillance, documentation, and reporting of infections, the facility was unable to provide any documented evidence of infection surveillance activities, line listings, or reporting data for an extended period covering several months. During the survey, the facility could not produce records or documentation related to infection tracking or follow-up activities in response to active antibiotic use, even though electronic records showed multiple antibiotic prescriptions for various infections over several months. Interviews with the DON and IP revealed that they were unaware of infection rates, lacked surveillance data, and did not have information on tracking, trending, or outbreak management. The DON stated reliance on verbal reports from nursing staff and admitted to having no data available, while the IP could not provide evidence of an infection prevention program, including antibiotic stewardship or vaccination tracking. Further, the Administrator acknowledged that the infection control program should be implemented and followed but was not aware of the current infection status in the facility, expecting clinical staff to manage these issues. The Medical Director, who started recently, confirmed the absence of an infection control program and stated that monitoring, tracking, and reporting of infections, as well as antibiotic stewardship and vaccination, were not being conducted as expected. No documentation was available to demonstrate compliance with infection prevention and control requirements.
Failure to Implement Antibiotic Stewardship and Infection Control Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program as required by its own policy and regulatory expectations. Record review showed that there was no documentation of tracking, follow-up, or review with the physician or nurse practitioner after antibiotics were prescribed for three active physician antibiotic orders. Additionally, there was no documented information related to antibiotic use or infection surveillance for a period spanning from August 2024 through June 2025. The facility's policy outlined the need for monitoring antibiotic use, staff education, and tracking of related issues, but these actions were not carried out. Interviews with facility leadership, including the DON, Infection Preventionist, Administrator, and Medical Director, confirmed the absence of an active infection control or antibiotic stewardship program. The DON was unable to provide infection rates or data, relying solely on staff reports. The Infection Preventionist could not produce evidence of any infection prevention activities, including line listings, tracking, or surveillance. The Administrator acknowledged that the program should be in place but was not aware of current infection data, and the Medical Director confirmed the lack of an infection control program, stating that monitoring and tracking were not occurring.
Medication Storage, Labeling, and Temperature Control Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications and biologicals. On one nursing unit, a medication cart was observed left unlocked and unattended, allowing access to medications by unauthorized individuals, including residents who were seen walking past the cart. The nurse responsible for the cart was unaware it was unlocked, and both the nurse and the Director of Nursing confirmed that medication carts are required to be locked at all times when not in use. Additionally, medications on one of the medication carts were not labeled or dated according to manufacturer guidelines. Specifically, a bottle of Artificial Tears Lubricant Eye Drops was found open and undated, and the nurse present could not confirm when it had been opened. The Director of Nursing stated that medications should be dated upon opening and that staff are expected to document this information on the bottle. Further deficiencies were found in the storage of medications requiring refrigeration. The medication refrigerator lacked a functioning thermometer, and temperature logs were incomplete, with only 12 out of 30 days documented for one month. The refrigerator was observed to be too warm, with condensation and melting frost present, and medications inside were wet to the touch. The Assistant Director of Nursing acknowledged the refrigerator was not maintaining proper temperature and that there was no record of how long it had been out of range. The Director of Nursing was unaware of the issue and stated that the affected medications would need to be discarded due to unknown temperature exposure.
Failure to Ensure Dignified Dining Experience Due to Inappropriate Resident Labeling
Penalty
Summary
Facility staff failed to ensure a dignified dining experience for residents on the first floor unit by referring to residents as 'feeders' rather than by their names. Observations included a CNA asking a nurse if a resident was a feeder and the nurse responding affirmatively without correcting the terminology. Additionally, a nurse was heard stating, 'We have a feeder left,' while gesturing to a resident at a table. The facility's policy requires staff to address residents by their names of choice and not by care needs or other labels. Both the Assistant Director of Nursing and the Director of Nursing confirmed during interviews that staff should not refer to residents as feeders.
Failure to Timely Report Serious Resident Injuries to State Agency
Penalty
Summary
The facility failed to report two significant incidents involving a resident to the state agency as required by their own policy and regulatory guidelines. The first incident involved a resident with severe cognitive impairment and dependency on staff for activities of daily living, who experienced a fall resulting in a head laceration that required a staple. The fall was unwitnessed, and the resident was found on the floor by staff. After being transferred to the hospital for evaluation and treatment, the resident returned with a staple in the forehead. Despite the seriousness of the injury, there was no evidence that the incident was reported to the state agency. The second incident involved the same resident, who suffered another unwitnessed fall while in a common area, resulting in a displaced fracture of the right femoral neck that required surgical repair. The resident, who does not ambulate independently and uses a wheelchair, was found on the floor and complained of severe pain in the right knee and lower leg, with visible swelling and deformity. Hospital records confirmed the fracture and subsequent surgery. The facility did not report this incident to the state agency until ten days after the fall, which was not in accordance with the required reporting timelines. Interviews with the Director of Nursing and the Administrator confirmed that both were aware of the incidents and acknowledged that the events should have been reported to the state agency as required. The facility's policy mandates immediate reporting of such incidents, especially those resulting in serious bodily injury, but this protocol was not followed in either case.
Failure to Develop Person-Centered Behavior Care Plan for Resident with Paranoia and Delusions
Penalty
Summary
The facility failed to develop a person-centered behavior care plan for a resident with a history of chronic paranoia and delusions. Despite documented evidence in the hospital discharge records and social work notes indicating the resident's diagnoses of schizophrenia, intellectual disability, and post-traumatic stress disorder, as well as specific behavioral concerns such as paranoia around certain staff and delusional beliefs, the care plan did not address these issues. The resident's behaviors included refusing medication from specific staff and expressing fear and distress related to past experiences, which were not reflected in the individualized care plan. Interviews with facility staff, including the Social Worker and Director of Nurses, confirmed that the resident's chronic paranoia and delusions were not included in the care plan, despite facility policy requiring comprehensive assessment and person-centered planning for residents with impaired cognition or mental illness. The omission was identified during a review of the care plan and supporting documentation, which failed to show any interventions or strategies tailored to the resident's behavioral health needs.
Failure to Follow Physician Orders for Oxygen and Enteral Feeding
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for two residents. For one resident with dementia and COPD, the facility did not have a physician's order specifying the amount of oxygen to be administered via nasal cannula, nor instructions on how often the oxygen tubing should be changed. Observations showed the resident consistently using oxygen at 4 liters with unlabeled and undated tubing, and both the ADON and DON confirmed the absence of a required physician's order and related care plan documentation. For another resident with respiratory failure, gastrostomy, tracheostomy, and quadriplegia, the facility did not implement the physician's order for enteral feeding. The resident was observed receiving a different formula and rate (Jevity 1.2 cal at 58 ml/hr) than what was ordered (Jevity 1.5 cal at 55 ml/hr). Nursing staff were unaware of the discrepancy until it was pointed out, and the DON confirmed that physician's orders should be followed as written.
Failure to Provide Timely Wound Dressing Changes
Penalty
Summary
Surveyors found that the facility failed to provide wound care in accordance with physician orders and professional standards for one resident. The resident, who had diagnoses including peripheral vascular disease, anxiety, and depression, was observed with a soiled dressing on the right ankle that was dated three days prior. The dressing was only partially covering the open wound and had visible yellow/brown drainage. Documentation in the Medication Administration Record indicated that nurses had recorded daily dressing changes as ordered, but direct observation by surveyors contradicted these records. Interviews with nursing staff confirmed that the dressing should have been changed daily according to the physician's orders. The Director of Nursing also stated that her expectation was for nurses to follow the physician's orders for dressing changes. The facility's policy on dressings did not specify adherence to physician orders, and the failure to change the dressing as required resulted in the resident having a soiled and exposed wound for at least three days.
Failure to Provide Ordered Range of Motion Care for Resident with Contracture
Penalty
Summary
The facility failed to consistently implement physician-ordered range of motion (ROM) care for a resident with a contracture in the left hand. The resident, who had severe cognitive impairment and functional limitations in both upper and lower extremities, had a physician's order and care plan directing staff to place a rolled washcloth in the contracted left hand every shift to prevent further deterioration. Despite this, multiple observations over consecutive days showed the resident lying in bed without the required facecloth in the left hand. Interviews with staff, including a CNA and a nurse, confirmed that the facecloth was not in place as ordered, and there was no documented rationale in the medical record for this omission. The Treatment Administration Record (TAR) indicated that the intervention was signed off as completed every shift, despite the facecloth not being present during surveyor observations. The Director of Nursing acknowledged that the facecloth should have been in place per the physician's order and that any deviation should have been documented.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately maintain the nutrition and hydration status of a resident by not ensuring that significant weight loss was properly assessed and continually monitored. The resident, who had a history of anxiety, depression, and bipolar disorder and demonstrated moderate cognitive impairment, experienced a substantial decrease in weight over several months. Weight records showed a loss of 26.7% from February to May, with missing weight documentation for March and no evidence of reweighs or physician notification regarding the significant weight loss. Dietary notes indicated the resident triggered for weight loss on multiple occasions, but interventions were inconsistently applied, and the resident sometimes declined supplements. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's weight loss. The nurse was unaware of the significant weight loss and did not know if the physician had been notified, while the Registered Dietitian expected nursing staff to identify and report significant changes. The DON confirmed expectations for monthly weights, reweighs, and notifications but was also unaware of the resident's weight loss and the lack of follow-up. The Medication Administration Reports did not indicate that the resident refused supplements, further highlighting gaps in monitoring and documentation.
Failure to Develop Trauma-Informed Care Plans for Residents with PTSD
Penalty
Summary
The facility failed to develop trauma-informed, person-centered care plans for two residents with documented histories of post-traumatic stress disorder (PTSD) and significant trauma. For one resident with schizophrenia, intellectual disability, and PTSD, the care plan did not identify or address trauma history, triggers, or interventions to minimize re-traumatization, despite hospital records indicating a history of abuse, family violence, and sexual assault. The Trauma Informed Care Assessment for this resident also failed to document any trauma, and both the Social Worker and Director of Nurses acknowledged that a care plan addressing these issues should have been in place. For another resident with anxiety, depression, bipolar disorder, and PTSD, the care plan did not address the resident's PTSD, history of suicide attempt, or identify triggers that could lead to re-traumatization. Medical records from a previous facility documented a suicide attempt and ongoing psychiatric care, but the Trauma Informed Care Assessment did not reflect this history. Staff interviews confirmed that the care plan should have included interventions for PTSD and suicide risk, but these were not present.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required by regulation. During a medication pass observation, one of two nurses made two errors out of 33 opportunities, resulting in a medication error rate of 6.06%. Specifically, a nurse did not follow physician orders for a resident by administering Lactase tablets after the resident had already consumed breakfast, instead of before the meal as ordered. Additionally, the nurse administered two sprays of saline nasal solution in each nostril, rather than the prescribed one spray per nostril. These errors were confirmed through observation, interview, and record review. The nurse acknowledged during an interview that the medications were not administered according to the physician's orders, stating that he should have given the Lactase before the meal and only one spray of saline per nostril. The errors directly impacted one resident who had orders for Lactase for lactose intolerance and saline nasal spray for dryness.
Inaccurate Documentation of Wound Care in Medical Records
Penalty
Summary
Surveyors found that the facility failed to accurately document wound care for one resident with peripheral vascular disease, anxiety, and depression, who had moderately impaired cognition. The resident was observed on multiple occasions with a soiled dressing on the right ankle, dated several days prior, which only partially covered an open wound and showed signs of drainage. Despite this, the Medication Administration Record (MAR) indicated that dressing changes had been documented as completed on three consecutive days. Interviews with nursing staff confirmed that the dressing had not been changed as recorded, and the Director of Nursing acknowledged the expectation for accurate documentation but could not provide a facility policy on the matter. The discrepancy between the observed condition of the dressing and the MAR entries demonstrated a failure to maintain accurate medical records in accordance with professional standards.
Failure to Offer Influenza Vaccine to Resident During Influenza Season
Penalty
Summary
The facility failed to offer the Influenza vaccine to one resident out of a sample of five during the influenza season, as required by facility policy. The policy states that all residents and employees without medical contraindications should be offered the influenza vaccine annually, specifically between October 1st and March 31st. Record review showed that one resident had not been vaccinated for Influenza, and there was no documentation that the vaccine was offered upon admission or during their stay. Interviews revealed a lack of clear responsibility and tracking for the vaccination program. The DON stated she did not track vaccinations and expected the Infection Preventionist to do so, while the Infection Preventionist, new to the facility, was unaware of the vaccination program's status. The Administrator acknowledged the program should be implemented but was not aware of the current vaccination status, and the Medical Director expected vaccination status to be obtained on admission and the vaccine to be offered during influenza season.
Failure to Offer COVID-19 Vaccine to Resident Upon Admission
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to one out of five sampled residents, as required by its own policy and standard infection prevention practices. Record review showed that this resident had not been vaccinated for COVID-19, and there was no documentation that the vaccine had been offered upon admission or during their stay. The facility's policy, revised in January 2023, assigns responsibility to facility leadership and clinical staff to take reasonable measures to protect residents and staff, including offering the COVID-19 vaccine. Interviews revealed a lack of clarity and accountability regarding the vaccination program. The DON stated she does not track vaccinations and expects the Infection Preventionist to do so, while the Infection Preventionist, new to the facility, was unaware of the vaccination program's status. The Administrator acknowledged the program should be implemented but was not aware of the current vaccination status, relying on specialized staff to manage these requirements. The Medical Director, also recently appointed, reported hearing that residents had not been receiving COVID-19 vaccines and expected vaccination status to be obtained on admission and vaccines to be offered if not previously received.
Failure to Maintain Resident Hydration Leads to Hospitalization
Penalty
Summary
The facility failed to maintain the nutrition and hydration status of a resident who required assistance with eating and drinking, leading to hospitalization due to dehydration, acute kidney injury, and hypernatremia. The resident, admitted with conditions including cognitive decline and hypertension, showed a decline in self-feeding ability and required full assistance at meals. Despite recommendations for an occupational therapy evaluation, there was no indication that such an evaluation was conducted. Lab results indicated elevated sodium, chloride, and BUN levels, which were not addressed in a timely manner by the facility staff. The facility's policy on hydration and prevention of dehydration was not followed, as there was no documentation of a hydration protocol being initiated for the resident despite critically high lab values. The nurse practitioner did not address the elevated lab values, and there was a delay in sending the resident to the hospital after receiving notification of critically high sodium levels. The medical director stated that the nurse should have notified the nurse practitioner or physician immediately, considering the delay in treatment a significant issue.
Failure to Notify Physician of Critical Lab Results
Penalty
Summary
The facility failed to promptly notify the physician or nurse practitioner of critically high sodium levels for a resident, leading to a delay in treatment. The resident, who had severe cognitive impairment and required assistance with eating and drinking, was admitted with diagnoses including nontraumatic acute subdural hemorrhage, hypertension, peripheral vascular disease, and cognitive decline. Lab results indicated elevated sodium, chloride, and blood urea nitrogen levels, but there was no documentation that the physician or nurse practitioner was informed of these critical values. The lab company confirmed that a nurse was notified of the critically high labs, but the clinical record did not show that the physician or nurse practitioner was informed. Sixteen hours after the facility was initially notified of the elevated labs, the resident was sent to the hospital due to dangerously high sodium levels. The resident was treated in the hospital for hypernatremia, dehydration, and an acute kidney injury. The Medical Director stated that the nurse should have notified the physician or nurse practitioner immediately, considering this a delay in treatment.
Failure to Assess Hydration and Obtain Consent for IV Hydration
Penalty
Summary
The facility failed to meet professional standards of quality care for four residents by not properly assessing hydration status, obtaining necessary consents, and conducting required lab tests. For three residents, the facility administered intravenous (IV) hydration without assessing their hydration status through lab tests or obtaining consent from their health care proxies or guardians. This lack of assessment and communication was evident in the medical records, which did not document any hydration assessments or consent forms prior to the IV administration. In the case of one resident, the facility did not obtain the required Depakote level as ordered by the physician. Despite the physician's and nurse practitioner's notes indicating the need for a Depakote level check on a specific date, the facility failed to arrange for the lab draw. The Director of Nurses acknowledged that the lab draw could have been scheduled even though it was not the facility's regular lab day. Interviews with the Director of Nursing and the Regional Manager of the IV company revealed a discrepancy in the process of obtaining consent for IV hydration. The Director of Nursing stated that consent is always needed from the health care proxy or guardian before proceeding with IV hydration, while the IV technician expected the facility to have obtained consent prior. This inconsistency contributed to the failure to notify and obtain consent from the responsible parties before administering IV hydration.
Latest citations in Massachusetts
A resident with 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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