Admissions halted at nursing home

JAIME CAMPOS/Staff photoCareOne at Peabody has been ordered to stop admitting new residents after an inspection found "immediate jeopardy" at the nursing home.

PEABODY — Supervisors at a Peabody nursing home failed to investigate several incidents of sexual abuse by a resident this year, at one point telling a nurse who reported one incident that "nothing happened," according to an investigation by the Massachusetts Department of Public Health.

The reported abuse, at CareOne at Peabody, included the resident grabbing other residents by the genitals, forcibly rubbing up against them, pinning them against a wall, and pulling them onto a bed. After one incident, a resident who had been abused several times "buried his/her face into (a nurse's) shoulder and cried," the report said.

Despite the repeated incidents — at least nine over a five-week period in August and September against four different residents — CareOne failed to investigate or report them to the state, the report said. State inspectors uncovered the abuse after responding to a complaint in early November.

The Department of Public Health immediately halted admissions to CareOne and recommended that the federal government declare "immediate jeopardy" at the facility. The agency said the nursing home failed to ensure that residents were protected from abuse.

DPH spokeswoman Ann Scales said on Friday that CareOne had come back into "substantial compliance" with federal regulations, and the admissions freeze was lifted on Thursday. Any other penalties, such as federal fines, are at the discretion of the Centers for Medicare and Medicaid Services, she said. A spokesman at the federal agency did not return a message.

CareOne's administrator and director of nursing resigned in the wake of the investigation, and the resident accused of committing the abuse has been discharged from the nursing home, according to the report. 

The Department of Public Health released the investigation report on Friday following a public records request from The Salem News. It described nine separate incidents when workers at CareOne witnessed the same resident abusing four other residents. All five, including the perpetrator, have dementia, the report says.

Downplaying incidents

In at least three of the instances, supervisors appeared to ignore the incidents or diminish their seriousness. In one case, the director of nursing told a nurse to change his description of an incident on his witness statement from "grabbing" to "hugging." In another incident, a unit manager told a nurse that "nothing happened" because staff had intervened when the resident tried to pull another resident onto a bed.

On Sept. 7, an activities aide saw the resident grab another resident's genital area in the dining room, according to the report. When the aide told the director of nursing, the director said she wanted to determine for herself if the resident exhibited inappropriate sexual behaviors. 

According to several witnesses, the director of nursing said she was going to "flaunt myself" in front of the resident to see if he or she would do anything (residents' genders are not given in the report). A family member told investigators that the director of nursing "stuck her breasts forward while swaying her shoulders back and forth in front of Resident #1."

When Resident #1 did not react, the director of nursing instructed staff to bring back the resident who had just been grabbed by Resident #1 to see if Resident #1 would do anything else. When Resident #1 reached over and pulled the other resident's chair closer, the director of nursing intervened.

Witnesses said the director of nursing, who is not named, also asked the resident why he or she paid attention to the victim, who the director said was "not attractive." A witness said everyone at the table could hear that remark.

A nursing home administrator told investigators she was unaware of the allegations against the director of nursing until she was contacted by the Department of Public Health on Nov. 2. The administrator said she then suspended the director and began an investigation.

Doctors and health care agents for the residents who were victimized told investigators they were not immediately notified of the abuse.

Officials at CareOne at Peabody referred questions to Tim Hodges, the chief marketing officer for New Jersey-based parent company CareOne. In a statement, Hodges said the investigation was based on a "self-reported concern" and that the issues have been addressed.

"On (Dec. 19) the Massachusetts DPH determined that our center is in substantial compliance with all state and federal requirements," Hodges said. 

In a letter to DPH officials on Nov. 8, Administrator Laura Vigneau said CareOne at Peabody had "re-educated" its staff to ensure that allegations of abuse are immediately reported and investigated.

CareOne at Peabody, formerly called Peabody Glen, is located at 199 Andover St. on Route 114, across the street from the Northshore Mall, and has 150 beds.

CareOne at Peabody has an overall rating of below average, according to Medicare's Nursing Home Compare website.

Staff writer Paul Leighton can be reached at 978-338-2675 or

Recommended for you