MELROSE, MA - Federal inspectors documented multiple violations at Melrose Healthcare following a survey conducted in April 2025, revealing systemic failures in providing basic resident care, maintaining sanitary conditions, and following medical protocols.
Inadequate Assistance with Basic Daily Care
The facility failed to provide proper assistance with activities of daily living for seven residents, including critical failures in incontinence care and meal assistance. Inspectors found that multiple residents who required regular toileting assistance went hours without proper care, despite facility policies requiring checks every two to three hours.
Resident #14, who has severe cognitive impairment and is documented as incontinent of both bowel and bladder, was observed going from 8:25 AM to 1:00 PM without receiving any toileting assistance or incontinence care. When inspectors examined the resident at 11:39 AM, they found the incontinence brief was "heavily soaked with urine." A certified nursing assistant acknowledged that the resident should have received care every two hours but had not been attended to since 7:00 AM.
Similar patterns emerged with other residents. Resident #57, who requires toileting assistance and is frequently incontinent, was observed in the dining room for over five hours without receiving any incontinence care. When checked, this resident's brief was also heavily soaked, with urine having leaked onto clothing.
Failure to provide adequate incontinence care poses serious health risks including urinary tract infections, skin breakdown, pressure ulcers, and dignity concerns. Prolonged exposure to moisture can lead to painful skin conditions and infections that are particularly dangerous for elderly residents with compromised immune systems.
Meal Assistance and Nutrition Support Deficiencies
The inspection revealed widespread failures in providing necessary meal assistance to residents with documented eating difficulties. Multiple residents requiring supervision or assistance with meals were left unattended during feeding times, creating risks of choking, malnutrition, and inadequate nutritional intake.
Resident #70, who is legally blind and requires meal setup and supervision, was repeatedly observed with untouched meal trays that staff had not properly prepared. The resident was documented as needing "continual supervision" due to inability to sequence tasks and generalized weakness, yet was consistently left alone during meals with food containers the resident could not open independently.
Resident #4, who requires partial to moderate eating assistance due to severe cognitive impairment, was observed eating with hands, drinking oatmeal directly from bowls, and spilling food extensively without receiving appropriate guidance from nearby staff. During one observation, the resident dropped a cup that spilled on the floor, but staff did not intervene to assist.
Inadequate meal assistance can lead to choking incidents, aspiration pneumonia, malnutrition, dehydration, and weight loss. For residents with cognitive impairments or physical limitations, proper meal supervision and assistance are essential for maintaining adequate nutrition and preventing serious medical complications.
Unsanitary Living Conditions and Pest Infestations
Inspectors documented persistent problems with facility cleanliness and pest control that created an unsafe living environment. The second floor consistently had strong odors of "stale urine and body odor" throughout hallways and dining areas during multiple days of observation. Family members and residents complained about the persistent odors, with 14 out of 16 residents in a group meeting expressing concerns about the facility's smell.
One resident's room presented particularly concerning conditions. Resident #80's room consistently smelled strongly of urine and contained "greater than ten small black flying insects" throughout multiple days of inspection. The room also contained scattered food wrappers, open juice containers, and leaking condiment packets on surfaces and floors. Despite the resident's complaints to staff about the conditions, no effective remediation had occurred.
Poor sanitation and pest infestations create serious health hazards including increased infection risk, respiratory problems, and psychological distress. Flying insects can spread bacteria and contaminate food and surfaces, while persistent odors indicate underlying sanitation failures that can contribute to the spread of infectious diseases.
Medical Care Protocol Failures
The facility demonstrated concerning lapses in following medical protocols and physician orders. Inspectors found that a resident with a cardiac pacemaker lacked a comprehensive care plan with essential device information, despite facility policies requiring detailed documentation of pacemaker specifications, monitoring schedules, and cardiologist contact information.
Additionally, staff failed to properly implement physician orders for diagnostic testing. One resident's urine analysis, ordered to investigate potential medical concerns, was not processed in a timely manner despite being collected, creating delays in necessary medical evaluation.
Staff also improperly set medical equipment, with one resident's therapeutic air mattress consistently set to 300 pounds instead of the physician-ordered 150 pounds. This resident was at high risk for pressure ulcers, making proper mattress settings critical for preventing skin breakdown.
Failures to follow medical protocols can result in delayed diagnoses, inadequate treatment, worsening of medical conditions, and potentially life-threatening complications. Proper implementation of physician orders and medical device management are fundamental responsibilities of nursing home care.
Additional Issues Identified
The inspection revealed several other concerning practices including failure to file required grievance forms when residents reported missing personal items, inadequate care plan development for residents with histories of suicidal ideation, and failure to implement occupational therapy recommendations for residents with hand contractures. The facility also demonstrated lapses in ensuring expired legal treatment authorizations were renewed, potentially affecting residents' rights to refuse certain medications.
These violations collectively paint a picture of systemic care deficiencies at Melrose Healthcare, affecting residents' safety, health, dignity, and quality of life. The documented failures span basic custodial care, medical protocols, and facility management, indicating the need for comprehensive corrective action and ongoing oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Melrose Healthcare from 2025-04-09 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.