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State halts admissions to Mission Hill assisted living facility after inspection

Investigators found residents with dementia locked in their rooms

Landmark at Longwood, an assisted living facility.David L. Ryan/Globe Staff

State officials have suspended the certification of a Boston assisted living facility after inspectors discovered that employees were locking dementia patients in their rooms to enforce a quarantine aimed at controlling the spread of COVID-19.

Inspectors from the Executive Office of Elder Affairs found a host of problems at the facility, Landmark at Longwood, when they investigated last month, describing it as an “unsafe environment” for residents with dementia or memory loss. They noted that, when they visited, the reception desk was unstaffed and some aides failed to wash their hands or wear gloves.

Under the suspension, Landmark cannot accept new residents until the problems have been addressed.


“Please be assured that the suspension will have no immediate effect on your status as a Resident,” wrote Patricia C. Marchetti, the state’s director of assisted living certification and compliance in a letter to residents dated Aug. 27. “However, Landmark at Longwood will be required to make certain operational changes.”

It is the only time this year that an assisted living facility had its certification suspended, according to state officials.

The locks, which had been installed on several residents’ doors, were supposed to protect residents from coronavirus, families were told, and inspectors said they were removed at some point in July. But locks, considered “restraints” under state regulations, are forbidden, officials said, and raised concerns that a resident could have an emergency while locked inside.

Landmark officials did not return calls from the Globe. The 92-unit facility, which offers one-bedroom and studio apartments, is housed in the former Baptist School of Nursing in MIssion Hill. Its website says its offers concierge services, a full service salon, and a dining room with solarium.

Regulators visited Landmark at Longwood after receiving a complaint from a former employee, who cited a litany of alleged abuses, including the locked doors, medication errors, missing drugs, missing resident belongings, and verbal abuse of residents. The former employee shared these concerns with the facility’s executive director, the letter said, but “the concerns were not addressed.”


The whistleblower, who no longer works at Landmark, told the Globe that locks were placed on more than a dozen residents’ doors, though state investigators confirmed “at least two.” The former employee also filed a report with the Boston Police, alleging that some residents’ money had been stolen, medical documents were destroyed, and employees were instructed to “hide or not report” missing narcotics.

The daughter of one resident said she signed a release form authorizing the use of a lock on her mother’s door, although she says she didn’t completely understand what she was signing.

“I signed the form because I was told I had to sign the form,” said the woman, who asked not to be identified to protect her mother. “There were two options -- you consent or you get her out of here.”

Now, the woman said she feels naive for signing the contract, saying, There could have been an electrical fire, or anything.

It was the second time in two years that officials from the state Executive Office of Elder Affairs has found serious problems at Landmark, one of five assisted living residences owned by Landmark Senior Living. In May 2019, the state suspended its certification because of “widespread operational deficiencies which jeopardized resident health and safety,” according to an Aug. 25 letter to Landmark Longwood executive director David Santos from the state’s Marchetti.


In suspending its certification again on Aug. 25, officials said the facility can remain open but cannot accept new residents. It must submit a corrective plan within 30 days, officials said.

The family of the resident whose door was locked also filed a report with the Boston Police alleging that some of her belongings appear to have been stolen, including two cellphones and a pair of treasured earrings that she had worn for many years.

Her family relied on the phones to keep in touch with their mother, but its members now have to call the facility directly, and find getting through to their mother difficult.

“One day I made 20 calls trying to get through,” said the woman. “The phone rang and rang but no one picked up. "

State elder affairs officials said that the facility’s failure to comply with state regulations presents “a threat to the health, safety or welfare of its residents.”

Based on those findings, the facility may not accept new residents until state officials determine the facility is “in full compliance...with all applicable laws and regulations.”

It also ordered immediate corrective action -- a nurse must evaluate the skills of everyone providing personal care or dispensing of medication ’”including assurance that each is capable of demonstrating appropriate infection control technique,” and the facility must a plan to screen all visitors for COVID.

Landmark at Longwood has reported eight positive cases of COVID-19 -- all before June 17. No deaths were reported, according to state data.


Andrea Estes can be reached at andrea.estes@globe.com.