MELROSE, MA - Federal health inspectors cited Melrose Healthcare, a nursing facility at 40 Martin Street, for failing to provide treatment and care consistent with professional standards for two residents during an April 2025 survey. The deficiencies included six bilateral foot wounds left without assessment or treatment orders for three weeks and a pacemaker that went unmonitored for months.
Six Foot Wounds Left Untracked for Three Weeks
The most significant finding from the April 9, 2025, inspection involved a resident identified as Resident #9, who had been readmitted to the facility from the hospital on March 17, 2025. The resident, admitted originally in November 2024 with diagnoses including diabetes and mild cognitive impairment, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. The resident was unable to walk and depended entirely on staff for turning in bed, hygiene, and transfers.
When the resident returned from the hospital, the admission assessment documented eight separate wounds on both feet. These included two heel pressure ulcers — one on the right heel measuring 6 cm by 6.2 cm and one on the left heel measuring 4.8 cm by 6.5 cm — along with six additional wounds across both feet, including wounds on the left lateral foot, left ankle, right lateral foot, and anterior foot.
However, in the weeks that followed, only the two heel pressure ulcers received any clinical attention. The six additional wounds — described by staff as appearing to contain eschar, or necrotic tissue — received no wound treatment orders, no assessments, and no measurements from March 18 through the surveyor's observation on April 7, a span of three weeks.
On April 7 at 10:36 A.M., a surveyor observed a nurse performing a dressing change on the resident's bilateral heel pressure ulcers. During the observation, the six additional wounds were visible on both feet: two dime-sized wounds on the left lateral foot, one dime-sized wound on the left ankle, one dime-sized wound on the right lateral foot, and two dime-sized wounds on the anterior right foot.
The nurse performing the dressing change confirmed there were no wound treatment orders for the six additional wounds and stated she did not know what type of wounds they were.
A Breakdown in Responsibility
The inspection revealed a critical gap in accountability between the facility's own nursing staff and its consultant wound care provider. The facility's Director of Nursing (DON), who had personally completed the weekly wound evaluations, assessed and measured only the two heel pressure ulcers on the evaluations dated March 20, March 27, and April 3. None of these evaluations mentioned the six additional wounds.
Similarly, the consultant Wound Physician Assistant's progress notes from March 24 and March 31 contained no assessment or measurements of the additional wounds.
When interviewed, the DON said the consultant Wound PA was responsible for assessing and measuring all the wounds on the resident's feet and acknowledged the additional wounds had been present since the hospital readmission. The DON stated, "they spoke about the additional wounds weekly during risk meeting since his/her re-admission and they should have been assessed and measured weekly."
The consultant Wound PA offered a different account. She told inspectors she "only assessed any wounds addressed in his/her documentation and the facility was responsible for assessing and measuring any wounds that she was not following."
This disconnect meant that neither the facility's nursing staff nor the outside wound care consultant took ownership of monitoring six known wounds on a resident who could not advocate for themselves.
The facility's Regional Nurse confirmed during a follow-up interview on April 9 that the six additional wounds appeared to be arterial ulcers and should have been assessed and measured weekly.
Why Unmonitored Wounds Pose Serious Medical Risk
Arterial ulcers develop when blood flow to the extremities is insufficient, a condition particularly common in patients with diabetes. Unlike pressure ulcers, which result from sustained pressure on tissue, arterial ulcers signal underlying vascular disease and carry distinct treatment requirements.
The presence of eschar — dead, darkened tissue — in wounds is a significant clinical finding. Eschar can mask the true depth and severity of a wound beneath it, making regular assessment essential. Without consistent monitoring, clinicians cannot determine whether a wound is healing, stable, or deteriorating. In a diabetic patient, unmonitored foot wounds carry the risk of infection, which can progress to cellulitis, osteomyelitis (bone infection), sepsis, or in severe cases, the need for amputation.
Weekly wound assessments are a baseline standard of care in long-term care settings. These assessments involve measuring wound dimensions, documenting wound bed characteristics, noting any signs of infection, and adjusting treatment plans accordingly. The absence of any documentation for three weeks represents a fundamental lapse in wound care protocol.
The facility notably did not have a written wound care policy. The Regional Nurse told inspectors the expectation was for staff to follow physician orders and complete annual wound competency training, but no formal policy governed wound assessment procedures.
Pacemaker Monitoring Failures
The second deficiency involved Resident #20, admitted in October 2024 with diagnoses including dementia, heart failure, asthma, type 2 diabetes, and the presence of a cardiac pacemaker. The resident's BIMS score was 3 out of 15, indicating severe cognitive impairment.
The resident's hospital discharge summary from October 2024 specified that pacemaker checks were to be conducted remotely on three dates: October 23, 2024; January 22, 2025; and April 29, 2025. These remote checks are standard for patients with implanted pacemakers, allowing cardiologists to verify the device is functioning correctly, assess battery life, and detect any cardiac arrhythmias the device may have recorded.
According to the medical record, the first scheduled remote check on October 23, 2024, did not occur — a nursing note indicated the appointment was scheduled but "no call received." Inspectors found no evidence the check was ever rescheduled and no records indicating the resident was sent to a cardiologist for an in-person evaluation.
Surveyors observed the resident's room on two separate occasions — April 6 and April 8, 2025 — and found no pacemaker monitor present, which would be necessary for remote monitoring.
A nursing note from February 24, 2025, documented that the resident's Health Care Proxy asked about cardiology follow-up and pacemaker monitoring. The note indicated staff "reassured resident is being followed by cardiology and had a pacemaker check recently." However, the medical record contained no documentation that any pacemaker check had actually been completed.
When interviewed, the nurse assigned to the resident said she was aware the resident had a pacemaker but was "not sure how it is monitored or any other details." The DON told inspectors there should have been nursing progress notes about the pacemaker checks and said she believed the resident was going to outside cardiology appointments for monitoring.
The Medical Importance of Pacemaker Surveillance
Cardiac pacemakers require regular monitoring to ensure they are pacing the heart correctly, that leads (wires connecting the device to heart tissue) are intact and functioning, and that the battery has sufficient charge. For a patient with documented atrioventricular block — a condition where electrical signals between the heart's upper and lower chambers are delayed or blocked — the pacemaker is not an optional convenience. It is a life-sustaining device.
Remote pacemaker monitoring has become the standard of care, with major cardiology organizations recommending checks every three to six months depending on the device type and patient condition. Missed checks mean any device malfunction, lead displacement, or battery depletion could go undetected. In a patient with AV block, pacemaker failure could result in dangerously slow heart rates, fainting, heart failure progression, or cardiac arrest.
The fact that the facility told the resident's Health Care Proxy that monitoring was being conducted — when records showed it was not — adds an additional layer of concern, as family members relied on that assurance when making care decisions.
Regulatory Context and Facility Response
The deficiencies were cited under F-684, which requires facilities to provide treatment and care in accordance with professional standards of practice, resident preferences, and goals. The level of harm was classified as "minimal harm or potential for actual harm," affecting few residents out of a sample of 23.
While the harm classification may appear moderate, the underlying failures — unmonitored wounds in a diabetic patient with severe cognitive impairment and untracked pacemaker function in a resident with heart block and dementia — represent systemic breakdowns in care coordination. Both affected residents had severe cognitive impairment and were fully dependent on staff to manage their medical needs.
The facility is required to submit a plan of correction addressing these deficiencies. For complete details about these citations and the facility's response, readers can review the full CMS-2567 inspection report through the [Medicare.gov Care Compare](https://www.medicare.gov/care-compare/) website or by contacting the Massachusetts Department of Public Health.
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.
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