The incident happened the morning of May 27, 2026, at The Birches at Trillium Woods, a senior care facility in Plymouth.
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The inspection, conducted May 27, 2026, was a complaint investigation.
That was the reasoning offered by MA-B on May 26, 2026.
That is what inspectors documented at Dexter Health Care following a complaint inspection completed May 27, 2026.
Licensed nurses had been scheduled for every shift on each of those days.
Atrium Nursing and Rehabilitation began moving residents out on March 20, 2026.
The inspection, completed May 28, 2026, produced a deficiency centered on care planning.
The patient was Resident #1, a stroke survivor who cannot speak.
R806 said the nurse usually stays to watch them take the medications before leaving.
In this case, one resident, identified in inspection records only as R1, was the person at risk.
That is where the facility's own director of nursing said slings go when they are not in use.
Inspectors classified the violations as causing minimal harm or the potential for actual harm, and noted that a few residents were affected.