City nursing home cited for failing to stop physical and sexual abuse

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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.”

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.”

Email Grace Ferguson at gferguson@newbedfordlight.org

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