Melrose Healthcare: Improper Medication, Unsafe Staff Levels - MA

MELROSE, MA - Federal inspectors documented multiple serious violations at Melrose Healthcare during an April 2025 inspection, including the unauthorized administration of a powerful psychiatric medication to a vulnerable resident with dementia and chronic understaffing that left residents waiting hours for basic care.

Unauthorized Psychiatric Medication Administration

The most concerning violation involved a resident with severe dementia who was administered the antipsychotic drug Seroquel without required legal consent. The resident, who had been diagnosed with paranoid schizophrenia and dementia, was under special court protection requiring guardian approval for all psychiatric medications.

Despite having a "Rogers order" in place—a legal safeguard requiring a judge and legal guardian to decide when antipsychotic medications can be administered—nursing staff began giving the resident Seroquel 50mg twice daily on March 29, 2025. The medication was not included in the court-approved treatment plan, and neither the resident nor their legal guardian was informed about the new prescription.

Within days, nursing staff reported the resident had become unusually lethargic and sleepy. A nurse practitioner's note from April 3 documented that the resident was "more lethargic" and "sleeping most of the morning," eating less breakfast than usual. The note questioned why Seroquel had been started, stating there was "no note/no psych rec[ommendation]" and ordering the medication to be held.

The facility's Nurse Practitioner later told inspectors the resident "should never have been started on Seroquel," acknowledging it was administered without proper court consent and would likely have been ineffective for this particular resident.

Dangerous Oxygen Therapy Errors

Inspectors identified serious respiratory care violations affecting residents requiring oxygen therapy. Two residents received incorrect oxygen levels that could have caused dangerous carbon dioxide retention, a potentially life-threatening condition for patients with chronic obstructive pulmonary disease (COPD).

One resident with COPD was consistently receiving 5 liters of oxygen per minute, significantly above the prescribed 2-3 liters. The resident told inspectors they should be receiving 4 liters but noted that nurses set the machine levels. A facility nurse acknowledged the error, explaining that excess oxygen could cause carbon dioxide retention in COPD patients, a serious complication that can impair breathing function.

Another resident was receiving 4.5 liters of oxygen despite orders for only 1-3 liters per minute. Laboratory results showed elevated carbon dioxide levels in both residents, indicating their bodies were struggling to properly exchange gases—a direct consequence of receiving excessive oxygen.

Additionally, one oxygen concentrator had a filter covered in gray dust that nursing staff acknowledged should have been cleaned weekly. Dirty filters can reduce oxygen delivery efficiency and potentially introduce contaminants into the respiratory system.

Critical Staffing Shortages

The facility consistently failed to meet its own minimum staffing requirements, particularly on weekends, leaving residents without adequate care. Over a six-month period from October 2024 through March 2025, inspectors documented 19 weekend shifts where the facility operated below required Certified Nursing Assistant (CNA) levels.

During resident interviews, seven residents and one family member expressed concerns about inadequate staffing. One resident reported learning to change their own incontinence brief because "it takes too long for the call bells to be answered." Another resident stated call bells typically take "between a half hour to an hour" to be answered, especially on weekends.

During a resident group meeting, 10 out of 16 participating residents complained about long call bell response times and late medication administration due to weekend understaffing. Family members reported their loved ones sometimes did not receive meals due to insufficient staff.

Medication Security Breaches

Throughout the inspection period, surveyors repeatedly found medication carts, treatment carts, and medication rooms unlocked and unattended. These breaches occurred on both floors of the facility, creating potential safety hazards and violating federal requirements for secure medication storage.

On multiple occasions, inspectors were able to access medication carts containing residents' prescriptions and enter medication rooms with refrigerated medications while no nursing staff were present. Facility policy requires all medication supplies to remain locked when not directly attended by authorized personnel.

Fall Prevention Failures

The facility failed to properly implement fall prevention measures for a resident with dementia and a history of vertebral fractures from falls. After the resident experienced two documented falls, required interventions including one-to-one supervision were inconsistently provided.

Records showed the resident was supposed to receive 24-hour supervision following a March fall, but documentation revealed significant gaps in coverage. On multiple days, supervision was only provided for a few hours rather than continuously, and some days showed no supervision at all during certain shifts.

Nutritional Care Deficiencies

Two residents did not receive prescribed therapeutic diets designed to prevent choking and aspiration. One resident requiring nectar-thickened liquids was consistently served regular coffee because staff failed to mix the required thickening powder. Inspectors observed unopened thickening packets on the resident's meal trays multiple times.

Another resident on a mechanical soft diet and thickened liquids was inappropriately given crunchy Cheez-It crackers and regular water, both of which posed choking risks for someone with swallowing difficulties.

Wound Care Documentation Issues

Staff failed to properly document multiple wounds on a diabetic resident, potentially compromising care coordination. While the resident had bilateral heel pressure ulcers that were regularly documented and treated, six additional foot wounds were present but never recorded in weekly skin evaluations or care plans.

These undocumented wounds included multiple dime-sized areas of necrotic tissue on both feet that nursing staff acknowledged had been present since the resident's return from a hospital stay in March.

Infection Control Lapses

During wound care procedures, nursing staff repeatedly failed to perform proper hand hygiene between glove changes, potentially increasing infection risk. Inspectors observed a nurse changing gloves eight times during a single wound dressing procedure while performing hand hygiene only twice.

The nurse acknowledged the error, but this violation of basic infection control protocols created unnecessary risk for a vulnerable resident with multiple open wounds.

Administrative Oversight Failures

The violations revealed systemic issues with oversight and staff training. Three out of five licensed nurses lacked required annual wound care competency documentation, and five Certified Nursing Assistants had no annual performance reviews on file.

The facility's staff development position had been vacant for approximately a year, with responsibilities covered by various staff members without clear accountability for ensuring required training was completed.

Federal regulations require nursing homes to maintain adequate staffing levels, ensure proper medication administration, and provide appropriate clinical care to protect resident health and safety. The scope of violations at Melrose Healthcare indicates fundamental breakdowns in multiple care systems designed to protect vulnerable residents.

The facility must submit a plan of correction addressing each violation to demonstrate how it will prevent future occurrences and ensure resident safety.

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.

Melrose Healthcare: Improper Medication, Unsafe Staff Levels - MA