Inspection Findings Report

Benjamin Healthcare Center

Boston, MA • CMS ID: 225654.0

Report Summary

32 Findings Documented

Nov 2022 - Sep 2025 Date Range

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy reviews and interviews, the facility failed to investigate a potential incident of verbal abuse for 1 Resident (#61) out of a total sample of 19 residents.
Findings include:
Review of the facility policy titled, Abuse Prevention Program: Investigations, undated, indicated the following:
*The facility investigates all potential and actual abuse, and protects the residents during the investigation process from possible and actual harm.
*Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The Clinical Director is responsible for investigation if in the building.
*The individual conducting the investigation will, as a minimum:
a. Review the completed documentation forms
b. Review the patient's medical record to determine events leading up to the incident
c. Interview the person(s) reporting the incident
d. Interview the patient as needed
e. Notify Physician as needed to determine the resident's current level of cognitive function and medical concerns
f. Interview staff members who have had contact with the resident during the period of the alleged incident
*Witness reports will be obtained in writing. Either the staff member will write their statement and sign and date it, or the investigator may obtain the staff statement, read it back to the member and have him/her sign and date it.
*The Administrator will keep the resident and his/her representative informed of the progress with the investigation.
*The results of the investigation will be recorded and kept for records keeping.
Resident #61 was admitted to the facility in March 2018 with diagnoses including major depression.
Review of Resident #61's most recent Minimum Data Set, dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) of 15 out of a possible 15 indicating he/she is cognitively intact. The MDS also indicates Resident #61 requires extensive assistance for functional tasks.
During an interview on 11/16/22 at 10:00 A.M., Resident #61 said a Certified Nursing Assistant (CNA) called him/her a bitch twice. Resident #61 said he/she was very upset about this and discussed it with the Director of Nursing who the Resident said did nothing about it.
During interviews on 11/16/22 at 2:16 P.M., and on 11/17/22 at 8:50 A.M., the Director of Nursing (DON) said a CNA calling a resident a bitch would be considered verbal abuse. The DON said if verbal abuse is suspected a full investigation would need to be completed. The investigation would include interviewing the resident making the accusation, interviewing the CNA being accused, interviewing other staff working the shift the incident occurred on and interviewing other residents under the CNA's care. The DON said she would also suspend the CNA being accused until the investigation was complete. The DON said she recalled the incident with Resident #61 and said she interviewed the CNA and believed the CNA when she said she didn't call the Resident that name. The DON said she completed education with the entire staff to use respectful language towards all residents.
The DON provided the surveyor with an incomplete investigation that did not include the Resident's statement, resident interviews, staff statements and failed to indicate the CNA was suspended until the investigation was completed.

Event ID: 5L5N11

Stay Informed About This Facility

Receive email alerts when new inspection findings, staffing changes, or ownership updates are published.

Follow Benjamin Healthcare Center

Source: All findings sourced from official CMS Nursing Home Inspect records via ProPublica. This report presents factual government inspection data without ratings or recommendations.