Cura of Melrose

In the surveyor’s words

From the most serious findings on record at Cura of Melrose, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 8, 2026

  Based on interview and document review, the facility failed to provide adequate supervision to prevent the elopement for 1 of 1 residents (R1) reviewed who was identified as an elopement risk, required a WanderGuard (a wireless wander management system to prevent residents from wandering or eloping. It uses a wearable bracelet paired with door sensors to trigger instant alarms if a resident approaches an exit) device and had exit-seeking behaviors. This resulted in Immediate Jeopardy (IJ) when R1's WanderGuard device alarmed as she exited the building and staff responded by turning off the alarm without investigating who exited the door, she left the facility and independently ambulated approximately four blocks from the facility before being found, which placed R1 at likelihood for… […]

• Actual harm, isolatedF600May 14, 2026

  Based on interview and document review the facility failed to protect 2 of 2 residents (R2 and R1) from abuse. Staff used a personal cell phone to take a picture of R2's soiled brief, buttocks, and large bowel movement and the picture was sent to several other facility staff. This resulted in actual harm to R2 as she verbalized not trusting facility staff and was fearful to have a bowel movement. R1 was abused when staff used their personal cell phone to record R1's voice as she was repeatedly stating, help me, help me. The video was sent to several facility staff phones with the caption, I want to kill myself. The facility implemented corrective action, and the deficient practice was corrected on 5/08/26, prior to the survey, and was issued at past non-compliance. […]

• Actual harm, isolatedF689Jan 14, 2026

  Based on observation, interview and document review the facility failed to protect 1 of 4 residents (R1) from avoidable accidents when care plan interventions were not implemented. This resulted in actual harm to R1 who fell out of a recliner and sustained a large hematoma (a solid swelling of clotted blood) and laceration to the front of her head.Findings include: R1's admission Record indicated she admitted to the facility 8/26/24. R1's diagnosis included dementia, depression, overactive bladder and osteoporosis. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she required substantial to maximal assistance for transfers and toileting. R1's care plan revised 12/19/25, identified a potential for injury related to a history of falls. […]

• Actual harm, isolatedF689Dec 4, 2025

  Based on observation, interview and document review the facility failed to ensure the care plan was followed during staff assisted transfer for 1 of 3 residents (R1), who fell while being transferred. This resulted in actual harm when R1 sustained a fracture. Due to actions taken by the facility, following the fall, this is being issued at past non-compliance.Findings include:R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included Alzheimer's disease, vascular dementia with psychotic disturbance, age related osteoporosis, and R1 had moderately impaired cognition.R1's care plan revised on 12/1/25, indicated R1 had a self care deficit related to impaired mobility, Alzheimer's disease, depression, and a change in condition related to unknown… […]

• Actual harm, isolatedF686Jul 29, 2025

  Based on observation, interview, and document review, the facility failed to provide care consistent with professional standard of practice to prevent worsening of pressure ulcer identified on 6/20/25 for 1 of 3 residents (R1) reviewed when the facility failed to provide appropriate assessment and treatment. This resulted in actual harm to R1 when she was identified with stage 3 pressure ulcer at coccyx area during admission at the hospital on 7/15/25. Findings include: According to the State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities, revision 229, issued 4/25/25 a pressure ulcer and stage 3 pressure ulcer is defined as Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence… […]