BOSTON, MA - Federal inspectors identified serious safety violations at North End Rehabilitation and Healthcare Center during a May 2025 inspection, including a nurse with expired CPR certification performing life-saving procedures and widespread failures in medication security and resident care protocols.
Life-Saving Skills Compromised by Expired Certification
The most serious violation involved a nurse with expired CPR certification attempting to resuscitate a resident who was found unresponsive. During a February 2025 incident, Nurse #1 discovered an unresponsive resident who was designated as a "full code," meaning the person had consented to receive all life-saving measures.
The nurse's response revealed critical gaps in emergency preparedness. Rather than immediately beginning CPR, the nurse left the resident with a certified nursing aide to call 911 and retrieve emergency equipment. When CPR was finally initiated, it was performed by a nurse whose certification had expired six months earlier in August 2024.
CPR certification is fundamental to nursing practice in long-term care facilities. The American Heart Association emphasizes that immediate CPR can double or triple survival chances after cardiac arrest. Every minute of delay reduces survival probability by 7-10%. When performed by someone without current certification, the effectiveness of compressions, ventilation techniques, and proper sequencing may be compromised, potentially affecting patient outcomes.
The facility's own assessment acknowledged that staff must complete annual CPR competencies and maintain certification every two years. However, the system failed to track this critical requirement. During interviews, the Director of Nursing stated she was unaware of the expired certification and that the nurse "should not have provided CPR" without current certification.
The facility's oversight breakdown extended beyond this single incident. An audit conducted during the inspection revealed another nurse with expired CPR certification, indicating systematic failure in tracking and maintaining essential staff qualifications.
Medication Security Compromised Throughout Facility
Federal regulations require all medication carts and treatment supplies to remain locked when not actively supervised by authorized personnel. This requirement exists because unsecured medications pose serious risks including medication theft, accidental ingestion by confused residents, and potential medication errors.
Inspectors documented multiple instances of unsecured medication access on the facility's fourth floor. A medication cart was observed unlocked and unattended for four minutes while staff members, including a certified nursing aide, walked past without intervention. Treatment carts containing medical supplies were repeatedly found unlocked near the nurses' station, accessible to unauthorized individuals.
Medication security violations can have far-reaching consequences. Unsecured medications may be accessed by residents with cognitive impairments who might consume inappropriate substances. Staff unfamiliar with specific medications might inadvertently administer wrong dosages or medications. Additionally, controlled substances left unsecured create opportunities for diversion and abuse.
The facility's own policy clearly stated that medication compartments must be locked when not in use and that transport carts should not be left unattended if accessible to others. Despite these written protocols, staff consistently failed to implement basic security measures.
Feeding Tube Care Fails to Meet Medical Standards
Six of seven residents receiving tube feedings experienced violations of professional nursing standards, creating risks for malnutrition and infection. Tube feedings require precise monitoring because they deliver essential nutrition and hydration to residents who cannot eat normally due to swallowing difficulties or other medical conditions.
The violations included failure to properly label feeding bottles and water administration bags with dates and times, and incorrect administration of prescribed feeding volumes. For example, one resident was prescribed continuous nutrition at 55 milliliters per hour, but calculations showed significant discrepancies between prescribed amounts and actual delivery.
Proper tube feeding management is critical for resident survival. Unlabeled feeding solutions can become contaminated or spoiled, leading to serious infections. Incorrect feeding rates can result in malnutrition if too little is given, or aspiration pneumonia and other complications if too much is administered too quickly. The stomach and digestive system of tube-fed residents require carefully calibrated nutrition delivery to maintain health.
Three residents specifically experienced incorrect feeding volumes based on the time stamps and remaining quantities in their feeding bottles. One resident's feeding bottle showed that only 500 milliliters had been administered when 2,405 milliliters should have been delivered according to the prescribed rate and timeframe.
The facility's policy required feed formulas to be discarded 48 hours after opening, but lacked specific requirements for dating and labeling feeding equipment. This policy gap contributed to the unsafe practices observed during the inspection.
Respiratory Equipment Safety Overlooked
Two residents receiving respiratory support through ventilators or tracheostomy devices had equipment that exceeded safe replacement intervals. Respiratory tubing dated from mid-April was still in use during the May inspection, despite facility policy requiring weekly changes.
Respiratory equipment that remains in use beyond recommended timeframes becomes a breeding ground for bacteria and other pathogens. These microorganisms can cause pneumonia, respiratory tract infections, and other serious complications in residents who already have compromised breathing capacity. Residents on ventilators or with tracheostomies are particularly vulnerable because their normal respiratory defenses are bypassed.
The facility's policy required respiratory tubing changes every seven days, but no physician orders specified the change frequency. This created confusion among staff about when equipment should be replaced. One resident had a physician's order to change disposable equipment weekly, but the tubing observed was nearly two weeks old.
Medical Record Accuracy Compromised
Accurate medical records are essential for continuity of care and legal compliance. Inspectors identified two cases where documentation did not match actual care provided. In one case, respiratory therapy records indicated ventilator tubing had been changed on specific dates when physical inspection showed it had not been replaced.
Another resident's medication administration record showed nurses signing off on conflicting tube feeding orders - one for 9 A.M. to 6 A.M. administration and another for 9 P.M. to 6 P.M. administration. Nurses had signed both orders for multiple days, creating confusion about actual feeding schedules.
Inaccurate documentation can lead to dangerous care decisions. If records incorrectly show equipment has been changed, staff may not perform necessary maintenance, increasing infection risks. Conflicting medication records can result in overdosing, underdosing, or missed doses of critical treatments.
Quality Assurance System Fails to Prevent Incidents
The facility's quality assurance program failed to identify and address the death of a resident who required CPR from an uncertified nurse. Despite written policies requiring investigation of adverse events and root cause analysis, no formal investigation was conducted into this incident.
The facility's assessment stated that incidents would be reviewed to prevent reoccurrence and that root cause analysis would identify and address causal factors. However, the Director of Nursing stated she reviewed the medical record notes but "nothing stood out that would warrant an investigation."
Effective quality assurance programs are designed to identify system failures before they lead to serious incidents. The death of a full-code resident should trigger comprehensive review of emergency response procedures, staff qualifications, and equipment availability. Without this systematic approach, similar incidents may recur.
Additional Issues Identified
The inspection also revealed failures in pharmaceutical storage requirements and conflicts between written policies and actual practices. Treatment carts containing medical supplies were repeatedly observed unlocked despite clear policy requirements for secure storage.
The facility's assessment claimed comprehensive risk identification and mitigation programs, but the multiple violations across different departments suggested these programs were not effectively implemented or monitored.
Several residents receiving specialized medical care through feeding tubes, ventilators, and other complex equipment experienced substandard care delivery, indicating broader systemic issues in managing medically complex residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North End Rehabilitation and Healthcare Center from 2025-05-09 including all violations, facility responses, and corrective action plans.
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