HAVERHILL, MA - Federal inspectors discovered a certified nursing aide physically abused multiple residents at Wingate At Haverhill, including an incident that resulted in a resident's arm fracture, according to inspection records from January 2025.
The violations reveal a troubling pattern where facility administrators failed to properly investigate initial abuse allegations, allowing the same nursing aide to continue working and subsequently harm another resident.
Pattern of Physical Abuse Emerges
The incidents involved two residents who reported rough treatment by the same certified nursing aide, identified in records as CNA #5. The first incident occurred in November 2024 when Resident #95 reported that the aide handled them roughly during transfers and forced them to wear an incorrectly sized brief.
According to inspection documents, Resident #95 told staff that CNA #5 was rough when transferring them to the toilet and brought only a small brief instead of the extra-large size required. When the resident explained they needed a larger brief, the aide reportedly began counting down "5, 4, 3, 2, 1" and threatened to leave them in the bathroom if they didn't put on the small brief.
"Resident #95 said he/she forced the small brief on because he/she thought the CNA would leave him/her in the bathroom if he/she didn't put the brief on," the inspection report stated.
The more serious incident occurred in December 2024, involving Resident #1, who reported that CNA #5 forcefully pulled a laptop case handle from their arm, causing severe pain rated 8 out of 10. The aide also forcefully removed the resident's brief and made inappropriate comments about not having time to provide proper care.
Medical imaging revealed the incident resulted in a fracture of the left ulnar bone in the resident's forearm, though the exact timing of the fracture could not be determined from the X-ray.
Critical Investigation Failures
The facility's response to the first incident demonstrates significant failures in following their own abuse prevention policies. Instead of launching a formal investigation as required, administrators filed the November complaint as a "grievance" - a customer service issue rather than a potential abuse case.
Federal regulations require nursing homes to immediately investigate any allegation of resident abuse and place accused staff members on leave pending the investigation. The facility's own policy mandates thorough investigations including interviews with witnesses, the affected resident, and proper documentation.
However, inspection records show no formal investigation was conducted after Resident #95's complaint. The aide remained on duty, continuing to provide direct resident care until the December incident with Resident #1.
"The Administrator said that from her recollection, she believes it was a customer service issue and that is why she filed it as a grievance," according to the inspection report.
Medical Significance of Abuse Patterns
Physical abuse in nursing homes creates serious medical risks beyond immediate injuries. Rough handling during transfers can cause soft tissue damage, joint injuries, and fractures, particularly dangerous for elderly residents with conditions like osteoporosis.
The psychological impact proves equally concerning. Residents who experience abuse often develop anxiety around receiving care, may become resistant to necessary medical treatments, and can experience declining overall health outcomes due to stress-related complications.
Forced compliance with inappropriate medical equipment, such as incorrectly sized briefs, can lead to skin breakdown, urinary tract infections, and loss of dignity that affects mental well-being.
Regulatory Requirements Ignored
Federal nursing home regulations establish clear protocols for handling abuse allegations. Facilities must report suspected abuse to state authorities within two hours if serious bodily injury occurs, and must conduct comprehensive investigations that include:
- Interviewing all involved parties and witnesses - Placing accused staff on leave during investigations - Documenting findings thoroughly - Notifying residents and families of investigation outcomes - Reporting results to appropriate authorities
The inspection found Wingate At Haverhill failed to report the November incident to state authorities and did not conduct the required investigation procedures.
Additional Care Quality Concerns
Beyond the abuse violations, inspectors identified multiple other care quality issues affecting resident safety and well-being:
Fall Prevention Failures: One resident with moderate cognitive impairment experienced eight documented falls between November and January, including three skin tears from one fall. Despite having fall mats specified in their care plan, staff consistently failed to place the mats beside the resident's bed.
Medication and Treatment Errors: Staff failed to apply compression stockings as ordered for a resident with heart failure and leg swelling, despite documenting they had completed the task. Another resident with feeding tube orders received incorrect flush settings on their nutrition pump for multiple days.
Assessment Inaccuracies: The facility incorrectly completed required assessments, including failing to document a resident's feeding tube on federal forms and inaccurately recording dental conditions despite obvious tooth decay and missing teeth.
Professional Standards Violations
The violations demonstrate failures to meet basic professional nursing standards across multiple areas of care. Staff documented completing treatments they had not performed, failed to clarify conflicting physician orders, and did not follow established protocols for medical equipment maintenance.
For residents requiring specialized care like feeding tubes and oxygen therapy, proper monitoring becomes critical for preventing serious complications. The inspection found staff set medical equipment to incorrect settings and failed to perform required safety checks.
Administrative Response and Outcomes
Following the December incident involving Resident #1, facility administrators suspended CNA #5 pending investigation six days after the alleged abuse occurred. The aide was ultimately terminated in late December, though the administrator stated the termination was for "customer service and insubordination" rather than specifically citing the abuse allegations.
The delayed response and unclear reasoning for termination raise questions about whether the facility properly addressed the severity of the abuse allegations and took appropriate steps to prevent similar incidents.
Implications for Resident Safety
The violations at Wingate At Haverhill highlight systemic issues that compromise resident safety and quality of care. When facilities fail to properly investigate abuse allegations, they create environments where harmful behaviors can continue and escalate.
The pattern observed - an initial complaint handled as a customer service issue followed by more serious abuse - demonstrates why nursing home regulations require immediate and thorough responses to all abuse allegations, regardless of initial severity.
Federal nursing home regulations exist specifically to protect vulnerable residents who depend entirely on facility staff for their daily care needs. The investigation failures documented at this facility represent serious breaches of that protective framework.
The complete inspection report provides additional details about the facility's required corrective actions and timelines for addressing these violations. Families and residents can access this information through state survey agencies or the facility's administration to understand what steps are being taken to prevent future incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wingate At Haverhill from 2025-01-16 including all violations, facility responses, and corrective action plans.
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