BEVERLY — The Blueberry Hill Rehabilitation and Healthcare Center was cited for abuse after an inspection revealed multiple violations in caring for residents, including one that led a resident to contemplate suicide.
Over five days last October, state inspectors said they observed an understaffed nursing home that failed to train the staff it had, and that repeatedly made mistakes in how it cared for residents.
In one instance, a resident told inspectors that she was left to sit in urine for more than six hours when a nurse assistant refused to change her. She said the situation happened often and left her feeling “hopeless, sad, angry, helpless and start(ing) to have suicidal thoughts.”
Blueberry Hill, a 132-bed facility on Brimbal Avenue, also failed to maintain a “home-like environment,” according to the inspection report. Two of the facility’s three units had a strong odor of stale urine and feces throughout the hallway and dining area, inspectors said.
The Massachusetts Department of Public Health said Blueberry Hill is back in compliance by December. But the report prompted the federal Centers for Medicare & Medicaid Services to label Blueberry Hill with a red hand icon on its nursing home rating website.
The red hand means the nursing home has been cited for abuse, which the agency defines as “the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.”
In a prepared statement, Blueberry Hill Administrator Bashar Alghazawneh said the facility immediately developed and launched an improvement plan in response to the issues raised in the inspection. The plan included staff education, competency testing and ongoing monitoring in coordination with the Department of Public Health.
“We continually educate our staff on the prevention of abuse and neglect as part of our plan,” he said. “Blueberry Hill Rehabilitation & Healthcare Center is committed to providing high-quality care and a safe environment for our residents.”
Blueberry Hill had insufficient staffing levels for 135 of 153 days. Nurses and certified nursing assistants had not been adequately trained in such areas as infection control, catheter care, trach care and mechanical lifts, according to the inspection report. Blueberry Hill’s nursing director told inspectors that she had only been at the facility for a week and that staff performance reviews were “on her list of things to do.”
In all, inspectors cited 28 deficiencies over the five days. They included failing to flush feeding tubes, clean oxygen filters, and maintain accurate medical records. Nurses and cooks were seen failing to wash their hands or wear gloves when handling medication and food. Food in the kitchen, including sweet potatoes, tomatoes, lettuce and cucumbers, had “significant signs of decomposition.”
Several other items in a walk-in refrigerator were opened or uncovered. An open container of pudding in a storage area was surrounded by several small black flies, and a container of teriyaki sauce without a lid was covered with a “black wispy growth.”
The Centers for Medicare & Medicaid Services fined Blueberry Hill $60,755 for the violations. The facility was also hit with three fines totaling more than $46,000 in 2021 and 2022. It is ranked in the bottom 2% of nursing homes in the state, according to ratings by Massachusetts Executive Office of Health and Human Services.
Blueberry Hill is affiliated with Marquis Health Services, a New Jersey-based for-profit company that operates 64 facilities in nine states. The Marquis facilities have been fined 105 times for $2.4 million, and six have an abuse icon, according to CMS.
The Centers for Medicare & Medicaid encourages consumers who see an abuse icon to review inspection reports on its nursing home compare site, talk to the facility about their concerns, and learn what actions they have taken to address the issue. Locally, consumers can also contact Gloucester-based SeniorCare, which has an ombudsman program to assist North Shore residents of long-term care facilities and their families.
Staff Writer Paul Leighton can be reached at 978-338-2535, by email at pleighton@salemnews.com, or on Twitter at @heardinbeverly.