F0609

D

Failure to Timely Report Alleged Verbal Abuse to Administration and State Agencies

Lowell, Massachusetts Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that staff immediately reported alleged verbal abuse so that administration could timely notify required state agencies, as mandated by the facility’s Abuse, Neglect and Exploitation policy. That policy required all alleged violations to be reported to the Administrator, Medical Director, state agency, adult protective services, and other required agencies immediately, but no later than two hours after the allegation is made if the events involve abuse. Resident #3, whose diagnoses included traumatic brain injury, morbid obesity, and major depressive disorder, reported that on one morning around 10:00 A.M., a hospice aide called the resident a pig, said she would take the resident to the slaughterhouse to be slaughtered, said the resident was a dog who used to live in a cage, and that a CNA present in the room did not say or do anything in response. The Health Care Facility Reporting System showed that the facility’s report of an allegation of verbal abuse of this resident by the hospice aide was not created and submitted until 12/31/25 at 2:35 P.M., at least five days after one of the alleged verbally abusive incidents.

Interviews with staff revealed multiple failures to promptly report the alleged verbal abuse. CNA #4 stated that on two or three occasions, beginning approximately three to four weeks prior, she witnessed the hospice aide respond to racial slurs from the resident by calling the resident a “fat pig,” saying they were going to put the resident in a butcher shop because of having so much meat, and laughing, but she did not report any of these incidents until interviewed on 01/02/26 as part of a facility investigation. CNA #5 reported that around 12/25/25, after the resident directed a racial slur at the hospice aide, the aide replied that if she was the quoted slur, then the resident was fat, but CNA #5 assumed CNA #4 would report it and initially denied any knowledge of verbal abuse when questioned by the ADON, only later admitting she had witnessed the incident. The ADON and DON confirmed that both CNAs had failed to report the alleged verbal abuse when first questioned, despite the expectation that staff immediately report allegations of abuse per facility policy, and the Administrator reiterated that staff were expected to report suspected abuse immediately so the facility could report to required agencies within two hours.