BOSTON, MA - A federal inspection revealed that Presentation Rehab and Skilled Care Center failed to provide adequate respiratory care monitoring, contributing to a resident's death from respiratory failure in April 2025.
Fatal Respiratory Care Breakdown
The most serious violation occurred with Resident #109, who died after nursing staff repeatedly failed to respond appropriately to declining oxygen levels and respiratory distress. The resident, who had chronic obstructive pulmonary disease (COPD) and had been recently hospitalized for similar issues, experienced a gradual deterioration over several days before his death.
Medical records show that starting in late March, the resident's oxygen saturation levels consistently dropped to dangerous levels between 86-90%, well below the normal range. Despite physician orders requiring oxygen therapy when levels fell below 90%, nursing staff failed to consistently follow protocols or notify medical providers of the deteriorating condition.
The facility's own care plans required staff to monitor and report abnormal breathing patterns, administer nebulizer treatments as needed, and notify physicians of respiratory changes. However, inspection records reveal these critical interventions were not consistently implemented.
Critical Days Before Death
In the final days before the resident's death, documentation shows alarming signs that should have triggered immediate medical intervention:
- Oxygen saturation dropping to 86-88% on prescribed 2-liter oxygen - Use of accessory muscles for breathing - Increased confusion and restlessness - Fatigue so severe the resident could barely eat
Despite these clear warning signs, medical records show no evidence that physicians or nurse practitioners were notified of the declining condition. Additionally, ordered respiratory medications were not consistently administered during this critical period.
On the day of death, a nurse found the resident unresponsive in bed. Emergency services were called, but the resident had no pulse or respiration and was pronounced dead.
Medical Standards Ignored
Respiratory care protocols exist specifically to prevent such outcomes. When patients with COPD experience declining oxygen levels, immediate intervention is essential. The facility's nurse practitioner told inspectors that low oxygen levels must be addressed immediately, and that nursing staff should have notified medical providers of any decline in respiratory status.
The physician orders were clear: administer oxygen when saturation falls below 90%, provide nebulizer treatments every 4-6 hours as needed for shortness of breath, and monitor respiratory status every shift. None of these orders were consistently followed during the resident's final days.
Professional respiratory care standards require continuous monitoring of oxygen levels, prompt administration of bronchodilator medications, and immediate physician notification when patients show signs of respiratory distress. The resident's healthcare proxy expressed surprise at the sudden death, noting that respiratory failure was listed as the cause of death on the death certificate.
Widespread Care Quality Issues
The respiratory care failure was part of a broader pattern of care deficiencies found throughout the facility:
Abuse Investigation Failures: The facility failed to properly investigate two separate abuse allegations. One involved a staff member allegedly giving a resident the middle finger and using profanity, while another involved rough handling during personal care. Despite clear facility policies requiring immediate investigation and reporting, no formal investigations were conducted.
Fall Prevention Lapses: A cognitively impaired resident at high risk for falls was found multiple times without required bed alarms properly connected and with only one of two ordered floor mats in place. The disconnected alarm string and improperly positioned safety equipment put the vulnerable resident at unnecessary risk.
Medical Equipment Mismanagement: Air mattresses designed to prevent pressure sores were incorrectly calibrated on multiple occasions. One resident's mattress was set to 130 pounds when the resident weighed only 145 pounds, causing discomfort and potentially compromising skin integrity.
Basic Care Omissions: Documentation revealed that one resident with multiple sclerosis had not received required weekly showers, with the resident telling inspectors that "staff never offer him/her a weekly shower and he/she couldn't remember the last time he/she had an actual shower."
Food Safety and Quality Concerns
Beyond medical care issues, inspectors found significant problems with food service that affected multiple residents. Temperature readings showed:
- Scrambled eggs served at only 110-118°F (should be at least 145°F) - Milk and juice served at 51-54°F instead of the proper 38-40°F - Cold foods sitting at dangerous temperatures for extended periods
Seven residents specifically complained about receiving cold food, overcooked proteins, and overall poor meal quality during inspector interviews.
Regulatory Response and Accountability
The inspection identified violations across multiple federal nursing home regulations, including requirements for abuse prevention, care plan implementation, professional care standards, and basic activities of daily living assistance.
These violations demonstrate systemic failures in fundamental aspects of nursing home care: protecting residents from harm, providing medically necessary treatments, and ensuring basic comfort and dignity.
The respiratory care death particularly highlights how seemingly routine monitoring failures can have devastating consequences for vulnerable residents. When healthcare providers fail to follow physician orders or recognize medical emergencies, residents pay the ultimate price.
Federal regulations exist specifically to prevent these types of preventable deaths and ensure that residents receive the level of care they would expect in any healthcare setting. The facility's failure to meet these standards represents a fundamental breach of trust with residents and families who depend on professional medical care.
The inspection findings underscore the critical importance of consistent staff training, proper supervision, and accountability systems to ensure that all residents receive safe, dignified care regardless of their medical complexity or care needs.
For families considering nursing home placement, these inspection results demonstrate the importance of thoroughly researching facilities and understanding what warning signs to watch for during visits and care meetings.
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.
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