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Second death cited at Wilmington nursing home

State regulators declared this week that residents at a troubled Wilmington nursing home are in “immediate jeopardy” after a second resident’s death was blamed on substandard care.

Officials ordered Woodbriar Health Center to stop accepting new patients, threatened to remove it from government programs that cover most residents’ bills, and recommended fines as high as $10,000 a day until safety is restored.

Woodbriar Health Center was already under investigation after the December death of a patient two days after a staffer accidentally dropped her.

The latest sanctions, which represent a rarely issued penalty, were imposed in a letter sent to the nursing home Tuesday by the Massachusetts Department of Public Health.


“Facilities that fail to protect residents and meet appropriate standards of care will be held accountable,” the state health agency said in a statement late Wednesday.

Owners of the nursing home disputed the state’s findings.

Investigators discovered issues surrounding the death of the second resident when they visited Woodbriar on Monday to determine whether the nursing home had corrected problems uncovered after an earlier resident death, in December.

The more recent episode involved a resident who fell out of bed about 9 p.m. Feb. 8 and appeared to have no injuries, according to the state’s letter to Woodbriar. Nursing home workers put the resident back to bed, and contacted a physician who ordered them to check the resident every two hours for signs of medical problems until the next morning, and then check every four hours.

But the resident was found dead in bed by 5:30 the next morning, with no record the checks were done as required, according to the state’s letter.

“There was no evidence to indicate that following the fall, the facility’s policies and procedures regarding neurological checks were reviewed, and that all staff were trained on assessing and documenting a resident’s status following a fall,” the letter states.


Two days before the Feb. 8 fall, another frail Woodbriar resident, who was supposed to be assisted when walking, fell and dislocated a hip, according to the letter.

Yet a staffer who watched the resident walking without assistance was unaware aid was needed because medical records were not sufficiently updated to reflect that need, the letter said.

Woodbriar is part of a problem-plagued chain of 11 nursing homes owned by Synergy Health Centers, a New Jersey company that has faced mounting citations for substandard care — medication errors, poor infection control, inadequate staff training — since buying its first Massachusetts facility in 2012.

A Synergy spokesman Wednesday said in a statement the company “strongly” disagrees with the state’s latest findings, saying the penalties will create “unnecessary confusion and disruption for our residents.”

Synergy will appeal the findings while also working with state and federal regulators to resolve the problems, the company said.

“For the sake of our 100-plus residents, we hope to resolve this matter quickly,” the statement said. “Woodbriar remains a safe, quality, skilled nursing facility.”

State regulators were inspecting Woodbriar on Monday to determine whether the nursing home had corrected problems associated with the Christmas Day accident involving Mary Meuse, an 83-year-old resident who was dropped from a mechanical lift.

Investigators had earlier concluded that three shifts of nurses knew Meuse broke her legs in the fall but failed for 24 hours to let her, or her family, know the results. Meuse, who was taking blood thinning medication for heart problems, was bleeding internally from her injuries. She died Dec. 27.


In the wake of the latest death, state regulators have ordered Woodbriar to take immediate actions “to prevent further harm to residents.”

The state’s letter to Woodbriar said the department is recommending federal regulators impose an immediate financial penalty between $3,050 and $10,000 a day, until the problems are fixed. The state is also recommending Woodbriar be terminated from Medicaid and Medicare, the government health programs that pay its bills, if conditions do not substantially improve by April 14.

The immediate steps ordered by the state include a review to ensure all residents are receiving the supervision and care they need to prevent further accidents; a special focus on residents known to be at risk for falls or accidents; and staff training to ensure proper training to respond to residents who fall or are involved in other accidents.

The health department has not completed its investigation of the February death at Woodbriar, and is still reviewing documents submitted by the nursing home. The department did not state when it expects to complete that investigation, but said it would send the nursing home its findings shortly.

Regulators are also working to finalize their recommendations for penalties stemming from Meuse’s death in December.

The results of the state’s probe into the December death were turned over to federal authorities last month.

Helen Mulligan, spokeswoman for the Centers for Medicare & Medicaid Services, said in an earlier interview with the Globe that federal regulators would determine exactly how much Woodbriar will be fined for the Meuse death.


The state’s letter to Woodbriar detailing its findings of substandard care in the Meuse fall was dated Feb. 9 — the day the second Woodbriar resident was discovered dead after a fall.

Kay Lazar can be reached at Kay.Lazar@globe.com Follow her on Twitter @GlobeKayLazar.