Presentation Rehab: Abuse Investigation Failures - MA

The July 2024 abuse allegation was one of three separate reports that the facility failed to properly investigate, according to federal inspectors who found the nursing home violated its own written policies for protecting residents from harm.

Resident 16, who has dementia and depends on staff for daily care, reported that a nursing assistant delivered their meal tray on July 21, 2024, nearly dropping it on the floor. The employee "said that she was not going back in the room for nothing she said he/she had no manners and the fuck you and then gave him/her the finger on the way out of the door," according to the grievance form filed two days later.

The resident's roommate witnessed the incident and confirmed seeing the nursing assistant give Resident 16 the middle finger while leaving the room.

Despite having detailed written policies requiring immediate investigation of abuse allegations, facility managers treated the incident as a customer service issue. The social worker who handled grievances told inspectors he provided "staff education" but never interviewed any employees or identified who was involved.

"Both issues should have been investigated and reported to identify the staff involved and to address any other concerns by residents to keep them safe," the social worker admitted to inspectors in April.

The same resident had filed another grievance three months earlier describing a different incident of verbal abuse. On June 17, 2024, Resident 16's family reported that staff spoke rudely while providing care, telling the resident to "stop pooping," then left them naked for an hour and a half after changing them.

The facility's written abuse prevention policy, dated March 2022, states that staff members "implicated in a potential neglect or abuse incident will be removed immediately from all resident areas" and "suspended from work pending the result of that investigation."

None of that happened.

A third case involved Resident 67, who has multiple sclerosis and moderate cognitive impairment. In February 2025, the resident reported that a tall female worker in a red dress "was rough with me and pushed me from side to side in bed" around 8 p.m. while changing wet sheets.

"She was upset and pushed me from side to side," the resident told staff the next day, according to a written statement. The employee had called for help from another worker, "but that girl didn't seem interested in helping out and left."

The Quality Assurance Nurse who responded to this allegation told inspectors she was "concerned for abuse" and worried about the resident's safety. But she never interviewed the staff members who were working that evening or tried to identify who was involved.

"I did not call or reach out to any staff members who were on the schedule who may have cared for the Resident," the Quality Assurance Nurse told inspectors. Instead, she provided "gentle handling" education to staff working the next day.

The facility also failed to report any of these incidents to state authorities as required by law, inspectors found.

During interviews in April, facility leadership acknowledged the failures. The Director of Nursing told inspectors that "allegations of abuse or neglect should be investigated and reported to validate concerns" and that "staff should have been identified, interviewed and called to obtain staff statements."

The Administrator said he expects staff to "follow-up immediately with any allegations of suspected abuse and report the suspected allegations to the state agency while the facility investigates."

But those expectations weren't followed. The social worker told inspectors he signs grievance forms "when he is told they are completed" but doesn't conduct interviews unless specifically directed by the Director of Nursing. The Director of Nursing said she doesn't have investigation files for any of these incidents and doesn't know who was involved in the residents' care.

The facility's own policy states that "all employees are responsible for identifying and reporting immediately to their supervisors or any witnessed abuse" and that supervisors must "take necessary steps to protect all residents" while immediately notifying leadership.

When an allegation is received, the policy requires the facility to "report and investigate all allegations of resident abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property" and "initiate an immediate investigation."

Resident 16's social service progress notes contained no information about either grievance filed on their behalf. The same was true for Resident 67's records regarding the rough handling allegation.

The Administrator told inspectors he was unaware that the rough handling incident had never been reported to state authorities. He said residents and staff should have been interviewed and statements obtained "to ensure no other resident has the same concerns."

Federal inspectors cited the facility for failing to implement its written policies for investigating abuse allegations, protecting residents during investigations, reporting findings, and taking corrective action to protect other residents from potential harm.

The violations affected residents with significant vulnerabilities. Resident 16 has dementia, difficulty swallowing, anxiety, depression, and weakness that makes walking difficult. They depend entirely on staff for daily activities like eating, bathing, and toileting.

Resident 67 lives with multiple sclerosis, muscle wasting, and anxiety. Their cognitive impairment means they scored only 10 out of 15 on a standard mental status assessment, and they require staff assistance with functional tasks.

Both residents remained in the facility's care throughout the period when their abuse allegations went uninvestigated, with no assurance that the staff members involved had been identified or prevented from working with other vulnerable residents.

The inspection found that facility managers discussed grievances during morning meetings with the Director of Nursing and Administrator, but these discussions never triggered the formal investigation process required by the facility's own policies.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Presentation Rehab and Skilled Care Center from 2025-04-28 including all violations, facility responses, and corrective action plans.

Additional Resources

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