Cura of Melrose

Inspectors wroteBased on interview and document review, the facility failed to provide adequate supervision to prevent the elopement for 1 of 1 residents (R1) reviewed who was identified as an elopement risk, required a WanderGuard (a wireless wander management system to prevent residents from wandering or eloping. It uses a wearable bracelet paired with door sensors to trigger instant alarms if a resident approaches an exit) device and had exit-seeking behaviors. This resulted in Immediate Jeopardy (IJ) when R1's WanderGuard device alarmed as she exited the building and staff responded by turning off the alarm without investigating who exited the door, she left the facility and independently ambulated approximately four blocks from the facility before being found, which placed R1 at likelihood for serious harm or death. [...]

Inspectors wroteBased on interview and document review the facility failed to protect 2 of 2 residents (R2 and R1) from abuse. Staff used a personal cell phone to take a picture of R2's soiled brief, buttocks, and large bowel movement and the picture was sent to several other facility staff. This resulted in actual harm to R2 as she verbalized not trusting facility staff and was fearful to have a bowel movement. R1 was abused when staff used their personal cell phone to record R1's voice as she was repeatedly stating, help me, help me. The video was sent to several facility staff phones with the caption, I want to kill myself. The facility implemented corrective action, and the deficient practice was corrected on 5/08/26, prior to the survey, and was issued at past non-compliance.

Inspectors wroteBased on observation, interview and document review the facility failed to protect 1 of 4 residents (R1) from avoidable accidents when care plan interventions were not implemented. This resulted in actual harm to R1 who fell out of a recliner and sustained a large hematoma (a solid swelling of clotted blood) and laceration to the front of her head.

Inspectors wroteThe facility failed to implement care planned interventions to reduce the risk for burns for 1 of 4 residents reviewed (R4) who spilled hot coffee on herself. R4's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included parkinsonism, depression, anxiety and dementia. R4's care plan dated 12/11/25 identified intact cognition and indicated she was able to eat independently. The care plan identified a risk for altered nutritional status and directed staff to provide covered mugs for hot liquids outside the dining room. R4's Hot Liquid Safety Evaluation dated 9/19/25, indicated temperature of liquid not to exceed 180 degrees. The evaluation indicated R4 had an isolated event on 9/16/2025, follow up completed on 9/17/2025. Standard temperature of hot liquid supplied by facility was less than 180 degrees. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to ensure the care plan was followed during staff assisted transfer for 1 of 3 residents (R1), who fell while being transferred. This resulted in actual harm when R1 sustained a fracture. Due to actions taken by the facility, following the fall, this is being issued at past non-compliance.

Inspectors wroteBased on interview and document review, the facility failed to submit a report with sufficient information to describe the alleged violation to the State Agency (SA) without omitting information or misleading information to make the incident appear less serious than it was for 1 of 1 residents (R1) reviewed.

Inspectors wroteBased on interview and document review the facility failed to notify the Ombudsman of transfers and discharges for 1 of 3 residents (R6) reviewed for hospitalizations.

Inspectors wroteBased on document review and interview the facility failed to ensure monthly pharmacy reviews were accurately completed and included review of hospital discharge orders for 1 of 3 residents (R6) reviewed for hospitalizations.

Inspectors wroteBased on observation and interview, the facility failed to maintain safe storage of medications on 1 of 3 medication carts when medication cart was left unlocked.

Inspectors wroteBased on interview and record review the facility failed to maintain a complete, accurately documented, and readily accessible medical record in accordance with accepted professional standards of practice for 1of 24 residents (R1) reviewed for advanced directives documentation. This deficient practice gave staff access to inaccurate information.

Inspectors wroteBased on observation, interview, and document review, the facility failed to properly disinfect shared equipment between use for 1 of 2 glucometers (medical device used to check blood sugar levels) reviewed for infection control.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide care consistent with professional standard of practice to prevent worsening of pressure ulcer identified on 6/20/25 for 1 of 3 residents (R1) reviewed when the facility failed to provide appropriate assessment and treatment. This resulted in actual harm to R1 when she was identified with stage 3 pressure ulcer at coccyx area during admission at the hospital on 7/15/25.

Inspectors wroteBased on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R1) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review the facility failed to implement adequate use of personal protective equipment (PPE) and hand hygiene during direct care services for 1 of 1 resident (R3) who required enhanced barrier precautions (EBP) with an indwelling device and open wound with a dressing change.

Inspectors wroteBased on record review and interview the facility failed to provide a reasonable call light response time for 4 of 4 (R27, R13, R36, R10) residents reviewed for dignity.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement interventions to prevent further development of decreased range of motion and ability for 2 of 2 residents (R29, R53) reviewed for positioning and mobility.

Inspectors wroteBased on interview and document review the facility failed to inform a responsible party in advance of the risks/benefits and receive informed consent of proposed care for 2 of 5 residents (R16, R19) reviewed for unnecessary medications.