Brandon Woods of New Bedford received more health citations than any other nursing home in Massachusetts last year.
by Grace Ferguson
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| Exterior of Brandon Woods nursing home in New Bedford. Credit: Eleonora Bianchi / The New Bedford Light |
A New Bedford nursing home has been cited for
more health and safety violations than any other nursing facility in
Massachusetts, and more than 99% of nursing facilities in the country.
State inspectors discovered that Brandon Woods “failed to provide a
safe environment free from physical abuse, sexual abuse, and neglect,”
and cited it for 44 violations, according to a December 2024 inspection
report. Three of the violations posed “immediate jeopardy to resident
health or safety,” and another five caused “actual harm.”
The Centers for Medicare and Medicaid Services has flagged the
facility for abuse and fined it $464,490, the largest single fine for a
Massachusetts nursing home in at least three years, according to The
Light’s analysis of federal data. Brandon Woods of New Bedford received
more citations in its last inspection cycle than 99.5% of nursing homes
in the country, The Light’s analysis found.
According to an inspection report, one resident of the dementia unit
would “wander into female residents’ rooms, stand at their bedside
watching them and fondle his/her genitals.” The inspection also
uncovered instances of residents hitting each other, which the nursing
home mostly didn’t report.
Staff knew about the behavior, but didn’t have care plans in place to stop the abuse, the inspection report said.
Many of the other citations had to do with substandard medical care
for residents. In one case, a resident developed a necrotic bedsore. The
facility’s staffing was below federal requirements, and a dangerously
low number of staff had completed required training, the inspection
said.
Nursing homes must meet federal requirements for health and safety to
be eligible for Medicare or Medicaid funding. These requirements are
enforced through inspections conducted by state agencies — in
Massachusetts, the Department of Public Health does these inspections.
Elder advocates who reviewed the December inspection’s findings said
they were appalled by the number and severity of the violations.
“It’s abhorrent,” said Paul Lanzikos, co-founder of Dignity Alliance Massachusetts, a coalition of senior and disability advocacy organizations. “It’s really reprehensible.”
This isn’t the first time Brandon Woods of New Bedford has faced significant penalties. It reached a $52,000 settlement
with the state’s attorney general in 2022 to resolve allegations that
staff failed to reposition a resident for weeks, causing bedsores and a
rapid decline in health before the resident died in a hospital.
Essex Group Management, headquartered in Rowley, Massachusetts, owns Brandon Woods of New Bedford and eight other
senior care facilities in the state. The company has appealed the
findings of the inspection, also known as a survey, according to Chief
Operating Officer Scott Picone.
“The company feels that the survey is incorrect,” he said in a phone
interview. He declined to comment further or provide a copy of the
appeal because the appeal is still open.
Medicare records show some of the chain’s other nursing homes, Brandon Woods of Dartmouth and facilities in Milford and Tewksbury,
also received low ratings for overall quality and health violations
since 2024. Medicare fined each of the three facilities last year, with
penalties ranging from $3,387 to $38,610. The number and severity of
their violations are nowhere near those of the New Bedford facility. The
chain’s two nursing homes in Worcester received above-average overall ratings. None of these five facilities are flagged for abuse.
Health inspectors visited Brandon Woods of New Bedford in November
2024 and issued their findings in a report the following month. The
facility’s last inspection before that was completed in August 2023.
Brandon Woods of New Bedford was found to be back in compliance
during an inspection in February, according to Katheleen Conti, a
spokesperson for the Massachusetts Department of Public Health. Conti
declined to make any officials available for an interview or answer a
list of written questions. She referred a Light reporter to officials
responsible for public records and said the department doesn’t comment
beyond what’s already in the public inspection documents.
The nursing home submitted a “plan of correction” to state health
officials. The Light’s public records request for a copy of the plan and
other compliance documents remains “under review,” according to a state
records officer, with no timetable for completion. The Light started
requesting these records from the agency at the beginning of August. The
Massachusetts public records law normally requires a response in about
two weeks.
The Light spoke with relatives of three Brandon Woods residents who
gave accounts of their parents’ experiences there. Taken together, their
accounts include assault, inattentive staff, and disorder.
Lori Smetanka, executive director of the National Consumer Voice for Quality Long Term Care,
said the violations indicate that this nursing home is a “troubled
facility.” She said the facility would need to demonstrate that
meaningful changes had been made to prevent further harm to residents.
“We should not be accepting this — it doesn’t have to be this way,” she said.
Sexual abuse violations
The person at the center of the abuse violations at Brandon Woods of
New Bedford is identified only as Resident #77 in inspection documents —
the names and genders of residents were not described in inspection
records. Of the 44 citations the nursing home received in this
inspection, 10 were linked to the way it responded to Resident #77’s
inappropriate behaviors.
When this resident lived on the first floor of the facility, they
“would stand outside women’s rooms and egg them on verbally and with
sexually inappropriate gestures,” according to a therapeutic activity
director quoted in the inspection report. The behavior apparently didn’t
stop when the resident was transferred to the dementia unit — that’s
when Resident #77 started exhibiting “hypersexual” behavior and
wandering into female residents’ rooms, a psychiatric nurse practitioner
told the inspector.
The nurse told the inspector that he tried to get updates on Resident
#77 from other employees, “but the challenge is that there is such
great turnover in staff, many don’t know anything about the Resident,”
the inspection said.
The inspection uncovered several inappropriate incidents documented in Resident #77’s medical file.
Nurse’s notes said the resident “smacked one of the female residents
in the butt,” and “was observed wandering during the night and
intrusively entering other residents’ (female) rooms and touching
his/her privates.” The resident also “fixated on one particular female
resident and follows her around the unit,” a nurse told an inspector.
Another nurse told an inspector that Resident #77 was “verbally
sexually inappropriate toward staff, kissing female residents’ arms, and
trying to get females to lay in bed with him/her.” She said Resident
#77 “called her over to him/her, grabbed his/her own genitals and shook
it at her.”
“The Nurse said she reported the behaviors to staff (could not
remember who) and was told it was baseline behavior for the Resident and
he/she always does that,” the inspection said.
Other nurses interviewed for the inspection said they didn’t try reporting the behavior to a supervisor.
“Review of the medical record failed to indicate any protective
measures were put in place to protect any residents from Resident #77’s
violent, sexually inappropriate behavior,” the inspection said.
Staff told an inspector that the only form of increased supervision
in the dementia unit was “purposeful rounding,” which they defined as
staff walking around the unit and checking on resident rooms. But
there’s no schedule dictating which staff are responsible for doing
this, and no documentation to confirm it gets done. Staff said they
“just assume everyone is doing it,” the inspector wrote.
In less than three months, Resident #77 struck or sexually harassed
other residents on four separate occasions, according to medical records
cited in the inspection. The records show Resident #77 was hit by
another resident in two other incidents in late 2024. Only one of the
six incidents was properly reported, the inspection said.
The director of nursing told the inspector that she didn’t know about
the repeated resident-on-resident abuse. She said Resident #77 should
have received one-on-one supervision and been sent to the hospital for a
psychiatric evaluation after the incidents, according to the inspection
report.
The nursing home “probably would not have accepted the Resident back
after hospitalization because they are not able to care for his/her
behavioral needs,” the director of nursing told the inspector.
A social worker told the inspector that families of other residents
had complained about Resident #77. The nursing home’s administrator,
Ricot Octave, told the inspector he was aware of the violent and sexual
behavior and that it should have been investigated, but couldn’t explain
why it wasn’t.
“He said they tried to transfer the Resident to another facility for
the safety of the Resident and other residents, but the Resident’s
spouse and daughter became upset and were adamant that he/she not be
moved,” the inspection said.
There’s no record in the inspection documents of Resident #77 or their family denying the alleged behavior.
In one document, a person identified as Resident Representative #2
said “she did not agree” with an administrator’s suggestion that
Resident #77 be transferred to another facility, “because the facility
was too far away and the Resident’s spouse would not be able to visit
him/her very often. She said she is very grateful that the Administrator
is allowing the Resident to remain in the facility despite their
concerns about the safety of other residents.”
“We should not be accepting this — it doesn’t have to be this way.”
— Lori Smetanka
Inspection documents don’t say whether Resident #77 is still living
in the facility, and the spokesperson for the state’s Department of
Public Health didn’t answer The Light’s question about it.
Lanzikos, the Dignity Alliance leader, said Resident #77’s behavior
isn’t unusual in a dementia unit, but the facility’s behavior was.
“It’s the lack of an effective response on behalf of the facility’s management,” he said. “That’s what’s unheard of.”
Smetanka agreed. She said it’s “unacceptable” that staff seemed to
accept the inappropriate behavior and didn’t have interventions to
address it in the resident’s care plan.
Lanzikos said he found it hard to believe that the director of nursing didn’t know about the behavior.
“The director should know about virtually everything that’s happening
on the units and the director should be walking the units on a daily
basis,” he said.
It wasn’t only Resident #77 — there was also Resident #60, a dementia
patient who exhibited “hypersexual behaviors” on at least three
documented occasions. Nursing notes said that resident had a history of
“trying to kiss other residents and grabbing their breasts.” The
inspection didn’t go into more detail.
Care that didn’t meet standards
The state inspector found numerous instances where medical care
didn’t meet standards and care plans didn’t meet residents’ needs.
Resident #72 developed a bedsore that later turned necrotic. The
resident was at high risk for bedsores and should have had a written
plan in place to prevent them, but didn’t, the inspector found. After
staff discovered the bedsore, a unit manager “forgot” to develop a care
plan with preventive measures, and no care plan was developed for
another three weeks, according to the inspection.
The inspector also noted that staff didn’t use proper hygiene when changing Resident #72’s dressing.
Smetanka, the consumer advocate, said this example suggests that other types of care are also being missed.
“If people are being forgotten and not receiving care to the point
where a bedsore gets to that point, clearly they’re not getting the care
that they need,” she said.
Resident #102 was particularly vulnerable — with dementia,
depression, and bipolar disorder — and the inspection said they received
substandard care. The resident’s physician was months behind on signing
medical orders, and a nurse said the doctor “does not come into the
facility very often.” The resident’s doctor did not address the
pharmacist’s “repeated recommendations” to evaluate the resident’s
antipsychotic medication orders, according to the inspection. The report
doesn’t make clear whether the doctor was employed by the nursing home.
The resident missed a dose of an antibiotic for a urinary tract
infection because nurses failed to notify the physician of medication
availability issues, the inspection said. Nurses also didn’t ensure the
resident’s injection sites were rotated, falling short of care
standards, it said.
Resident #25, who uses a scoot chair for mobility, was not being
transferred to a regular armchair for meals as recommended by an
occupational therapist, the inspection said. This meant the resident had
to eat with the dining table at chin-level.
“Nobody saw that happening and questioned whether that was an appropriate thing?” Smetanka said.
An inspector watched for 13 minutes as Resident #67, another dementia
patient, tried to leave their room. They couldn’t get out because a
“stop sign” barrier had been put across the door to deter Resident #77
from entering, the inspection said.
Resident #79 had lived at the facility for three years but had no
active care plan to address their dementia, according to the inspection.
Resident #83 was required to be seen by a doctor every 60 days, but went 224 days without a visit, the inspection said.
Nurses failed to complete a bladder scan that a doctor had ordered
for Resident #63, who was having incontinence problems, according to the
inspection.
Resident #363’s family wanted to revoke the resident’s
do-not-resuscitate order, but was stopped by administrative hurdles,
according to the inspection.
Medical records were not accurate for Residents #64, #25, #2, #83,
and #102, and Resident #112’s medical record was incomplete, the
inspection said.
Other citations suggest broader problems at Brandon Woods of New Bedford.
Nurse staffing was below standards on some weekends, and an inspector
had trouble finding detailed, up-to-date staffing information that
should have been readily available, according to the report.
Medicare data shows the facility has above-average nursing staff
turnover, with registered nurse turnover nearly double the national
average — 80% of registered nurses left Brandon Woods of New Bedford in a
one-year period, while the national average was 44%.
Low staffing is a common problem contributing to poor conditions in
nursing homes across the country, Smetanka said. She was concerned about
a note in the inspection that high turnover made it hard for a nurse to
get updates on Resident #77.
“That’s probably one of the biggest failures there,” she said. “When there’s turnover in staff, they don’t know the residents.”
She said the violations made her question whether top management at
Brandon Woods of New Bedford was doing enough to watch over the
facility.
The inspection found that most staff weren’t receiving required
training. Less than a third of staff had completed abuse or infection
control training in the year before the inspection. Only 15% had
completed behavioral health training.
Just 10% of staff had completed quality assurance training, a figure
the facility’s staff development coordinator called “shockingly low,”
according to the inspection. The coordinator admitted to an inspector
that the low training rates were unacceptable.
Other citations in the report say that infection control plans were
below standards, some medications weren’t stored properly, and some food
safety practices weren’t followed.
Resident experiences vary
The daughter of one Brandon Woods resident said she tells everyone
she knows not to send their loved ones to the nursing home. She
requested that her and her father’s names not be published for fear of
retaliation by the nursing home.
The woman’s father, who has Alzheimer’s disease, has fallen six times
in three years, she said. Some falls sent him to the hospital for head
and hip injuries, she said. The nursing home doesn’t always call her
after these incidents, she said — instead, she finds out when she calls
the nursing home to check in on her father, or when her father tells the
hospital to call her.
“He’s supposed to be buckled in a chair, so how is he falling?” she wondered.
The woman said she doesn’t visit often because she has health
conditions and receives near-constant notifications from the nursing
home that there are active COVID-19 cases. The woman said she has asked
repeatedly to do video calls with her father, but the nursing home
hasn’t followed through.
During one visit about a year ago, the woman said she saw residents
half-dressed and arguing with each other, while nurses chatted around
the nurse’s station. She said she could hear residents wandering into
each other’s rooms and being told by the other residents to leave. The
facility smelled like human waste, she said.
Her father’s room was “always a mess,” she said. On the day she spoke
to a reporter, she said she’d had yet another heartbreaking phone call
with her father: he’d asked to come home.
“I can’t help him,” she said. “He’s in a place that’s supposed to be
able to help him and take care of him the way it’s supposed to.”
Picone, the representative for the nursing home’s parent company,
disputed some of the woman’s account in an email to The Light. He wrote
that the facility’s last COVID-19 outbreak was more than six months ago,
and residents have video calls with family members “frequently and or
daily.”
Addressing the woman’s report that her father had frequent hospital
visits for falls, Picone wrote: “The Facility does not restrain
residents to prevent falls, but they do attempt to mitigate falls and
injuries. Should an individual fall it is commonplace to have the
resident evaluated at the hospital for injuries.”
The nursing home housekeeping “works diligently to ensure an odor
free environment,” Picone wrote. Addressing the woman’s descriptions of
half-dressed residents arguing with each other, he said the facility is
“unaware of a specific incident occurring.” He wrote that when nurses
are at the nurse’s station, they are collaborating on resident care with
doctors and other staff.
In response to the woman’s description of her father’s “messy” room,
Picone wrote: “Residents’ rooms are considered their personal space
although encouragement to be neat and tidy is addressed.”
Jennifer Morrisey Souza’s mother, Kathleen Morrisey, passed away at
Brandon Woods of New Bedford in July. When Morrisey Souza heard from a
Light reporter about Resident #77, she remembered complaints her mother
had about people in her doorway.
“She complained about a guy — she called him a ‘pervert,’” Morrisey
Souza said. “But my mom, with the dementia, I didn’t know what was real
and what was not half the time.”
Overall, Morrisey Souza said her mother had a good experience at the
facility. The room was clean and the nurses were kind, she said. But she
believes her mother received such high-quality care because her mother
was a nurse for the facility in the early 2000s. She said the
administrator was a family friend.
Morrisey Souza wasn’t surprised that Brandon Woods of New Bedford had
topped the state in the number of health violations. She said the smell
of urine would hit her immediately when she walked into the living
areas of the facility. There were never enough staff, she said, and the
ones that were there seemed disengaged.
“They would have like 20 patients parked around a TV, and the nurses would be chilling at the nurse’s station,” she said.
The facility’s financial office was often weeks late in releasing the
remainder of her mother’s Social Security checks (the amount left after
a payment to the facility). After her mother’s death, it took multiple
phone calls to get the facility to fulfill an agreement to pay the
funeral home, she said.
“All residents are treated equally, without preferential treatment,” Picone wrote in an email to The Light.
In response to Morrisey Souza’s reports of delayed payments, he
wrote: “Once all accounts are reviewed a check is mailed directly to a
funeral home at the family request.”
Picone wrote that residents are allowed to watch TV programs of their
choice, and the facility has a “robust activity schedule for numerous
events during the day and early evening.”
Frank Sullivan’s mother, Helen Sullivan, also passed away in the
facility’s dementia unit earlier this year. He remembers seeing one
resident, a “big, strapping guy,” wandering the halls and talking to
himself.
“I gotta keep an eye on this guy,” he remembers thinking.
In spring or summer 2024, Sullivan recalled, he got a call from the
nursing home: His mother needed to go to St. Luke’s Hospital because
another resident had hit her in the back of the head during a lunchtime
activity.
He remembers asking if it was that resident he was worried about.
According to Sullivan, the nurse on the phone said they couldn’t tell
him who it was but confirmed “unofficially” that it was that resident —
and they were seeking to transfer him somewhere else.
Sullivan said he asked the nurse if incidents like that happen a lot. “It can happen,” was the nurse’s reply, he said.
Fortunately, Sullivan said, his mother was fine when he met her at
the hospital, and she didn’t remember the incident because of her
Alzheimer’s disease. He said he didn’t see the resident who hit her
again.
Sullivan said he was surprised by the facility’s inspection results —
his family had a good overall experience with Brandon Woods of New
Bedford. He said he was grateful the facility accepted his mother after
she was asked not to return to her previous nursing home, where she
slapped a nurse within half an hour of moving in.
Picone wrote in an email to The Light that incidents “of any nature”
are reported to a physician, the family or legal guardian of the
“responsible party,” and the Massachusetts Department of Public Health.
Nursing home gets one star out of five from Medicare
The Centers for Medicare and Medicaid Services gives nursing homes
ratings on a five-star scale, with five stars going to the best
facilities.
Brandon Woods of New Bedford has a one-star overall rating. That’s
the lowest rating a nursing home can get without being dropped out of
the ratings system altogether and put on Medicare’s Special Focus Facility List.
Nursing homes on this list “have a history of serious quality issues”
and are subject to extra enforcement to get back on track. They risk
being terminated as a Medicare facility if they don’t show meaningful
improvement.
Brandon Woods of New Bedford is a candidate for being added to the list, Medicare records show.
Many of the nursing home’s quality measures for short stays are in
line with or better than national averages. But key quality measures
show that long-term residents at Brandon Woods of New Bedford lost their
ability to walk and perform daily activities independently at far
higher rates than the national average.
“Would you want your mother or grandmother in a place like this?
Would you want to live there too?” Smetanka asked. “If you wouldn’t want
to live in a place like this, it shouldn’t be acceptable for another
person to live in a place like this.”
Full Article & Source:
City nursing home cited for failing to stop physical and sexual abuse
