BOSTON, MA - A federal inspection of North End Rehabilitation and Healthcare Center found that a nurse with an expired CPR certification attempted to resuscitate an unresponsive resident who subsequently died, triggering an immediate jeopardy citation — the most serious level of deficiency federal regulators can assign. The May 2025 survey also uncovered widespread failures in tube feeding management, unsecured medication carts, and falsified medical records at the 70 Fulton Street facility.
Nurse's CPR Certification Had Lapsed Six Months Before Resident's Death
The most critical finding involved Resident #89, a full-code resident — meaning the individual had consented to receive all life-saving measures. The resident had diagnoses including chronic kidney disease, hypertension, and type 2 diabetes, and had severely impaired cognition.
According to the inspection report, a nurse identified as Nurse #1 entered the resident's room at approximately 5:00 a.m. to change a feeding and observed that the resident's chest was not rising and falling. The nurse documented that the resident "was warm to touch but without response and no pulse."
Rather than immediately beginning chest compressions, Nurse #1 left the resident in the room with a certified nursing aide, then went to call 911, page a code blue overhead, and retrieve the facility's crash cart before initiating CPR. When emergency medical services arrived and assessed the situation, they indicated the resident may have died approximately one hour earlier.
Federal investigators determined that Nurse #1's CPR certification had expired in August 2024 — six months before the incident occurred. The facility's own assessment required staff to receive annual CPR competencies and renew CPR certification every two years.
The American Heart Association states that immediate CPR can double or triple chances of survival after cardiac arrest, making the delay and the expired certification particularly significant. When a cardiac arrest occurs, every minute without CPR reduces survival odds by approximately 7 to 10 percent. The sequence Nurse #1 followed — leaving the resident to make phone calls and gather equipment before beginning compressions — represents a departure from standard emergency response protocols, which prioritize starting chest compressions immediately while directing others to call for help and retrieve equipment.
Facility Failed to Investigate the Death
Beyond the CPR failures, inspectors determined that North End Rehabilitation never conducted a proper investigation into the resident's death through its Quality Assurance and Performance Improvement (QAPI) program — despite the facility's own written policies requiring root cause analysis of adverse events.
The Director of Nursing told investigators she "reviewed the notes in the electronic medical record and said that nothing stood out to her that would warrant an investigation of the situation." She also confirmed she was not aware that Nurse #1 did not start CPR immediately until surveyors brought it to her attention.
The facility had implemented a code sheet system to track full-code incidents, but the Director of Nursing acknowledged that no code sheet was ever completed for this resident's death. She also confirmed the facility had not conducted any mock code drills in the past year, contrary to what was indicated in its facility assessment.
The Administrator at the time of the event told inspectors that when a full-code resident dies, facility staff typically complete a code sheet and the Director of Nursing and physician review it. "The facility will typically look into an unexpected death to find out what occurred in real time," the Administrator said, but acknowledged this process was not followed.
The Medical Director told investigators the resident "was tricky because he/she had a lot of comorbidities, but was not considered an expected death because the Resident was not on hospice."
Staffing Gaps Left Certification Tracking Unmonitored
A contributing factor to the CPR certification lapse was a breakdown in administrative oversight. The Director of Nursing told investigators that both the Staff Development Coordinator and the Human Resources staff member had left the facility, and she had assumed responsibility for both roles in addition to her own duties.
During the survey, as part of the facility's plan to remove the immediate jeopardy finding, a facility-wide audit identified at least one additional staff member whose CPR certification had also expired. The facility acknowledged that an earlier audit of human resources and employee files conducted in January and February had not identified CPR certification as something to review.
Tube Feeding Violations Affected Six of Seven Residents
Inspectors also documented systemic failures in enteral nutrition management under F-Tag 0693. Of seven residents observed receiving tube feedings, six had deficiencies in how their feedings were administered or labeled.
The problems fell into two categories: unlabeled or undated feeding equipment and discrepancies between the amount of nutrition that should have been delivered based on physician orders and what was actually administered.
For three residents — #40, #71, and #73 — inspectors found significant volume discrepancies that raise questions about whether residents received their prescribed nutrition:
- Resident #40 had a tube feeding bottle dated two days prior. Based on the prescribed rate and elapsed time, approximately 2,090 ml should have been administered, but the bottle indicated only 1,200 ml had been delivered. - Resident #71 had a bottle dated 5/2/25. Calculations showed 2,405 ml should have been instilled, yet only 500 ml appeared to have been given. - Resident #73 had a tube feed bottle also dated 5/2/25, running for approximately 35 hours. At the prescribed rate, 2,100 ml should have been delivered, but the remaining volume indicated only 1,150 ml was administered.
All six affected residents had diagnoses of protein-calorie malnutrition, and all were totally or substantially dependent on staff for daily living activities. Several had conditions including ALS, Guillain-Barre Syndrome, and Alzheimer's disease. When tube-fed residents do not receive their prescribed volume of nutrition, it can worsen existing malnutrition, impair wound healing, weaken immune function, and contribute to muscle wasting — particularly dangerous for individuals who are already malnourished and ventilator-dependent.
Proper labeling of tube feeding equipment with dates and times is not merely an administrative requirement. It serves as a critical safety check that allows staff across shifts to verify that feedings are being administered at the correct rate and that formula has not exceeded its safe use window. Without these labels, there is no reliable way to determine whether a resident is receiving adequate nutrition or whether formula has been hanging long enough to pose a bacterial contamination risk.
The Director of Nursing confirmed to investigators that "all enteral free water administration bags and tube feeding bottles should be labeled with the date and time hung as well as the prescribed rate of flow" and that "nurses should be checking to make sure that the prescribed amount to be instilled over a specific period of time was administered as ordered."
Respiratory Tubing Left Unchanged for Weeks
Two ventilator-dependent residents were found to have respiratory tubing that had not been changed according to facility policy or physician orders. Resident #47's tracheostomy tubing was dated April 13 — more than three weeks before the May 4 observation. Resident #71's ventilator tubing was dated April 20, approximately two weeks old, despite a physician order to change all disposable equipment weekly on Wednesdays.
For Resident #71, inspectors found that a respiratory therapist had signed documentation on April 23 and April 30 indicating the tubing had been changed — when it had not. The Director of Nursing confirmed that "the respiratory therapists should not be documenting that they changed the tubing when they did not."
Ventilator tubing that is not changed on schedule can become colonized with bacteria, increasing the risk of ventilator-associated pneumonia — a potentially life-threatening infection, particularly for patients who are already critically ill and immunocompromised.
Medication Carts Left Unlocked and Accessible
The inspection also documented repeated instances of medication and treatment carts left unlocked and unattended on the fourth floor. On the morning of May 4, a surveyor found an unlocked medication cart in the hallway and was able to open drawers and access the cart's contents for four minutes without any staff member intervening. A certified nurse's aide walked past the open cart without stopping.
Between 8:03 and 8:41 a.m. that same morning, surveyors observed three additional instances of unlocked treatment carts near the fourth-floor nurse's station with no nurse present. Multiple staff members, including the Admissions Director, were observed walking past the unsecured carts without locking them.
Unsecured medication storage creates risks of drug diversion, accidental ingestion by cognitively impaired residents, and potential tampering. Federal and state regulations require all medication compartments to remain locked when not actively in use by authorized personnel.
What Comes Next
The immediate jeopardy citation for the CPR failure represents the highest tier of federal nursing home deficiencies. Facilities that receive this designation must submit a removal plan demonstrating the issue has been corrected and measures are in place to prevent recurrence. Failure to resolve an immediate jeopardy finding can result in enforcement actions including civil monetary penalties or termination from Medicare and Medicaid programs.
The full inspection report, including the facility's plan of correction, is available through the Centers for Medicare & Medicaid Services. North End Rehabilitation and Healthcare Center is located at 70 Fulton Street in Boston, Massachusetts.
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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