Merrimack Valley Health Center

F-F726

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 15016 potential for actual harm Based on record review, interview and observation, the facility failed for 1 (Resident #5) of 26 sampled Residents Affected - Few residents to set the air mattress pressure to the correct, physician-ordered setting. Specifically, the physician order indicated the air mattress should be set to 100 pounds (lbs.) and for three days the pressure was set to 400 lbs.

Findings include:

Resident #5 was admitted to the facility in April 2021, and had diagnoses which included diabetes and cerebral vascular accident. Resident #5 received hospice services.

Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated he/she had moderately impaired cognitive skills for daily decision making, dependence on staff for most activities of daily living, and was at-risk for the development of pressure ulcers. The MDS indicated the Resident had a pressure-relieving mattress.

Review of Resident #5's current care plan indicated he/she was at risk for the development of pressure ulcers. Interventions included the use of pressure relieving devices.

Review of Resident #5's physician order dated 8/3/23, indicated he/she may have an air mattress to relieve pressure, to ensure setting is at 100 [lbs.], is on and functioning and to be checked every shift.

Review of Resident #5's most recent weight in March 2024 indicated he/she weighed 91 pounds.

On 6/10/24 at 8:14 A.M., the surveyor observed Resident #5 lying asleep in bed on an air mattress set to 400 lbs.

On 6/11/24 at 8:31 A.M., the surveyor observed Resident #5 lying asleep in bed on an air mattress set to 400 lbs.

On 6/13/24 at 8:38 A.M., the surveyor observed Resident #5 lying in bed on an air mattress set to 400 lbs.

The surveyor attempted to interview Resident #5, but he/she did not respond to questions.

On 6/13/24 at 9:33 A.M., the surveyor observed Resident #5 lying in bed on an air mattress set to 400 lbs.

During an interview with Unit Manager #1 on 6/13/24 at 9:33 A.M., she said Resident #5 weighed approximately 96 pounds. The surveyor and Unit Manager #1 observed that Resident #5's air mattress pressure was set to 400 pounds. Unit Manager #1 said the Resident's air mattress pressure should be set to 100 pounds due to his/her weight.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 45763

Residents Affected - Few Based on observation, record review and interview, the facility failed to ensure the environment was free from accident hazards for one Resident (#74) out of a total sample of 26 residents. Specifically, the facility failed to implement an intervention intended to prevent further falls after Resident #74 sustained a fall.

Findings include:

Review of the facility policy titled Falls, revised June 2022, indicated the following:

- It is the policy of Mill Town Health and Rehab to make every effort possible to identify any resident at risk for a fall, prevent a fall and if a fall occurs to fully investigate the incident to identify any practices that need to be revised to further support the goal of fall prevention and resident safety.

- If a fall occurs, an Incident and Accident Investigation and an Incident/Accident Report is to be completed by the licensed nurse. The licensed nurse or department head will immediately obtain written statements from the CNA's (certified nursing assistants) and other assigned staff, as applicable, on the Post Fall Report.

A CQI Falls Assessment Tool is to be completed by a licensed nurse at the time of the fall. All of the documentations are to be completed and attached to the incident/Accident report with a Fall Screen or Evaluation Request, as indicated.

A. The charge nurse on duty will immediately assess the resident for any injury, pain and V/S. He/she will then implement a fall prevention plan immediately to prevent any future occurrences and document on the resident Care Plan and CNA Care Card once the resident is deemed stable.

- The supervisor will be notified by the charge nurse if a fall occurs. The supervisor will assess the fall. Supervisor will update and add information, as needed, to the CQI Falls Assessment Tool as well as to check for accuracy of the incident report, and then co-sign. The supervisor will also assess and add interventions to the care plan as needed.

- The Resident's care plan needs to be reviewed and updated every time a fall occurs to make sure the appropriate interventions are listed. All other logs and assignment sheets updated as needed for staff communication.

- All reports must be completed prior to weekly risk meeting and submitted to Director of Nursing (DON).

- An At Risk meeting is held weekly. The team, at minimum, includes DON, Nursing Supervisors, SDC (Staff Development Coordinator), Activity Director, Social Services, MDS (Minimum Data Set) staff, Reports from CNA's and a representative from the Therapy department. Other department heads/staff are welcome (and encouraged) to attend.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 - The Care Plan, CNA Care Card, Incident Report and CQI Falls Assessment Tool are to be brought to the meeting with the resident's chart. Level of Harm - Minimal harm or potential for actual harm - The team reviews residents who fell in the previous week, including incident outcome, follow up care plan and make any further recommendations necessary. Residents Affected - Few - The meeting also focuses on resident falls within the past month to continuously assess root cause/etiology of falls, evaluate effectiveness of current and new interventions, discuss additional new interventions, and assure new interventions followed through.

Resident #74 was admitted to the facility in March 2024 with a diagnosis of dementia.

Review of the most recent Minimum Data Set (MDS) assessment, dated 3/24/24, indicated that Resident #74 scored a 10 out of 15 on the Brief Interview for Mental Status exam indicating the Resident had moderate cognitive impairment.

Review of the Incident Investigation Summary Statement, dated 3/20/24, indicated Resident #74 had experienced an unwitnessed fall in his/her room on 3/20/24.

Review of the Fall/Incidents Risk Meeting Notes, dated 3/21/24, indicated Resident #74 had sustained an unwitnessed fall on 3/20/24 with the following intervention:

-Education on Call light use

Review of the Incident Investigation Summary Statement, dated 3/22/24, indicated Resident #74 had experienced an unwitnessed fall in his/her bathroom on 3/22/24. Review of the CQI Falls and Incident Assessment Tool indicated that the immediate new intervention/preventative measure was to advise to use call light at all times.

Review of the Fall/Incidents Risk Meeting Notes, dated 3/28/24, indicated Resident #74 had sustained an unwitnessed fall on 3/22/24 and that the Resident had not called for help on the 2nd shift.

Review of Resident #74's Falls care plan indicated that Resident #74 was at moderate risk for falls related to confusion, deconditioning, gait/balance problems, psychoactive drug use, unaware of safety needs:

-education regarding call light usage for safety, initiated 3/22/24.

Review of the falls care plan indicated that the intervention discussed at the 3/21/24 risk meeting to prevent future falls was not integrated into the Resident's care plan until 3/22/24, two days after the fall.

During an interview on 6/17/24 at 12:04 P.M., Certified Nursing Assistant (CNA) #5 said that Resident #74 has fallen in the past, and that the Resident occasionally rushes when getting out of bed.

During an interview on 6/17/24 at 12:37 P.M., Nurse (#2) said that after a resident falls they would be assessed, the physician would be notified, the fall would be discussed at risk, and new interventions would be implemented into the resident's care plan immediately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview on 6/17/24 at 12:50 P.M., Nurse Unit Manager (#2) said that after a resident falls, the nurse fills out the Incident Investigation Summary Statement, which would include updating the resident's Level of Harm - Minimal harm or care plan. Nurse Unit Manager #2 said the resident would then be discussed at risk meeting and that if an potential for actual harm intervention was discussed at risk meeting it should be integrated in the care plan immediately, during the risk meeting. Nurse Unit Manager #2 said that if the post-falls procedure wasn't followed that it would put Residents Affected - Few Resident #74 at risk for future falls.

During an interview on 6/17/24 at 1:07 P.M., the Director of Nursing (DON) said that after a resident falls the resident would be assessed, an incident report would be completed, the physician and family would be notified, and an intervention would be put in place immediately to prevent future falls. The DON said that if an intervention was discussed at risk he would expect it to be implemented and integrated into the care plan immediately. The DON said that if the post-falls procedure was not followed it would put the Resident at risk for future falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Provide care or services that was trauma informed and/or culturally competent.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41105 potential for actual harm Based on record review, policy review and interview the facility failed to ensure a plan of care was developed Residents Affected - Few for Trauma Informed Care, with individualized interventions, for three Residents (#70, #24 and #26) who have a history of trauma out of a total sample of 26 residents. Specifically:

1. For Resident #70, the facility failed to develop a trauma care plan, with individualized triggers and interventions, following an allegation of rape made by Resident #70 and failed to complete a PTSD assessment quarterly and following the allegation of rape.

2. For Resident #24, the facility failed to develop a comprehensive trauma care plan, with individualized triggers.

3. For Resident #26, the facility failed to develop a comprehensive trauma care plan, with individualized triggers.

Findings include::

The facility policy titled Trauma Informed Care Policy and Procedure, dated 9/2022, indicated the following:

-Trauma: Individual trauma results from an event, a series of events or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental physical, social, emotional or spiritual well-being. Trauma which produces Traumatic Stress, occurs when our coping mechanisms are overwhelmed by outside events.

-Procedure:

1. Facility residents will be assessed for past trauma and for signs/symptoms of traumatic stress upon admission, quarterly, annually and as needed.

2. If the results of these assessments reveal the presence of trauma or traumatic stress, the interdisciplinary team, in collaboration with the resident and with the approved resident's representative(s), will create a culturally sensitive plan of care to help prevent re-traumatization and to optimize quality of life.

3. These plans of care shall include prevention, intervention and treatment services that address traumatic stress and may include but are not limited to:

-A description of the resident's behavior(s) that is/are triggered by traumatic stress;

-Interventions that should be employed to avoid traumatic triggers;

-De-escalation interventions that should be employed when the resident is assessed to be exhibiting trauma-induced behaviors;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 -Directing staff behavior and interventions to help prevent re-traumatization.

Level of Harm - Minimal harm or 1. For Resident #70 the facility failed to develop a trauma care plan, with individualized triggers and potential for actual harm interventions, following an allegation of rape made by Resident #70 and failed to complete a PTSD assessment quarterly and following the allegation of rape. Residents Affected - Few Resident #70 was admitted to the facility in December 2023 and has diagnoses that include neoplasm of unspecified behavior of the brain (tumor) and generalized anxiety disorder.

Review of the most recent Minimum Data Set (MDS) assessment, dated 3/6/24, indicated that on the Brief

Interview for Mental Status exam Resident #70 scored an 11 out of 15, indicating moderately impaired cognition.

On 6/10/24 at 1:12 P.M., the surveyor met with Resident #70. Resident #70 almost immediately began crying and shaking as he/she told the surveyor that he/she had been raped by his/her brother in law a month or two ago while out of the facility for a visit with family. Resident #70 said that he/she does not receive support services at the facility but needs them. As well, Resident #70 expressed how sad he/she was because his/her sister was mad at Resident #70 when Resident #70 tried to tell her about the rape. Resident #70 said that the sister and brother in law are the only family that he/she has.

Review of the record indicated the following:

-Nurses note dated 4/26/24 at 10:40 A.M.: This RN was notified by activity's assistant that resident was in

the dining room crying and stating my brother raped me. SW (Social Worker) present on unit and notified of situation. She took resident off the floor to discuss.

-Social Service note dated 4/26/24 at 12:34 P.M.: SW was informed by nurse that Resident #70 told activity assistant that his/her brother-in-law raped him/her. SW asked if Resident #70 wanted to speak to her. He/she was in day room in activities waiting for his/her nails to be painted. Resident #70 open to conversation & [NAME] (sic) Resident #70 to her office. Resident #70 told SW that her brother-in-law raped him/her. SW asked more questions regarding details & collected information for statement. He/she reports being afraid of him & scared to tell us sooner. He/she states they are my only family. Resident #70 also reporting that his/her stomach hurts & that it hurts to pee. He/she also reports vomiting & having diarrhea when at his/her family's home. Resident #70 weepy & in distress while reporting all this information. He/she is agreeable to be sent to the hospital. IDT informed. SS will continue to follow.

Further review of the record indicated the following:

-The record failed to indicate that a Trauma Informed Care Review Assessment was completed following the alleged rape. The only Trauma Informed Care Review Assessment was completed on 12/5/23.

-The facility failed to develop a care plan to address Resident #70's traumatic event following a rape allegation that required a visit to the emergency room for a rape kit test and subsequent involvement by the District Attorney's (DAs) office and Protective Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 During an interview on 6/13/24 at 1:43 P.M., the facility SW (#1) says that the trauma assessment is completed by nursing and she completes a trauma care plan on admission. SW #1 said that a care plan Level of Harm - Minimal harm or should have been developed following the recent alleged rape and that she was not sure if a trauma potential for actual harm assessment should have been done.

Residents Affected - Few During a follow-up interview on 6/13/24 at 2:33 P.M., SW #1 said that she had discussed the situation with

the Director of Nursing (DON) and that the DON said that trauma assessments are completed quarterly and with a change and that Resident #70 should have had a trauma assessment after the rape allegation.

45343

2. Resident #24 was admitted to the facility in September 2022, and diagnoses including traumatic Post-Traumatic Stress Disorder (PTSD), bipolar, anxiety, and dementia.

Review of Resident #24's most recent Minimum Data Set (MDS) assessment, dated 3/12/24, indicated that Resident #24 had a Brief Interview for Mental Status exam score of 12 out of 15 indicating he/she has moderate cognitive impairments.

Review of the PTSD care plan indicated Resident #24 has a diagnosis of PTSD. The care had the following interventions:

-Arrange for me to see a psychiatrist if my physician thinks it would help.

-Connect me with a psychotherapist if my physician thinks it would help me.

-Monitor me to make sure that I can sleep.

-Monitor my appetite, watch me for weight gain or loss.

-Spend time with me so I have someone to talk to allow me to vent my feelings.

-Watch for signs that I may harm myself.

-Watch me for decreased interest in the things I used to enjoy doing as this may be a sign that my depression is getting worse.

Review of Resident #24's care plan failed to indicate the development of a comprehensive trauma informed care plan with identified resident specific triggers and interventions for his/her diagnosis of PTSD.

During an interview 6/13/24 at 1:41 P.M., the Social Worker (#1) said residents with PTSD should be formally assessed and a care plan should be developed with resident specific triggers identified.

3. Resident #26 was admitted to the facility in September 2023, and diagnoses including traumatic Post-Traumatic Stress Disorder (PTSD), depression, and anxiety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Review of Resident #26's most recent Minimum Data Set (MDS) assessment, dated 3/19/24, indicated that Resident #24 had a Brief Interview for Mental Status exam score of 15 out of 15 indicating he/she is Level of Harm - Minimal harm or cognitively intact. potential for actual harm

Review of the PTSD care plan indicated Resident #26 has a diagnosis of PTSD. The care had the following Residents Affected - Few interventions:

-Administer medications as ordered. Monitor/document for side effects and effectiveness.

-Assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these.

-Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.)

-Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness.

-Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis.

-Review of daily documentation indicating facility are implementing all interventions to the best of their ability, resident challenging impacting ability to implement all interventions daily.

Review of Resident #26's care plan failed to indicate the development of a comprehensive trauma informed care plan with identified resident specific triggers and interventions for his/her diagnosis of PTSD.

During an interview 6/13/24 at 1:41 P.M., the Social Worker (#1) said residents with PTSD should be formally assessed and a care plan should be developed with resident specific triggers identified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Immediate jeopardy to resident health or 45343 safety Based on record review, policy review, staff education record review, Facility Assessment review, and Residents Affected - Some interviews, the facility failed to ensure that the three out of thirteen nurses (Nurse #5, #6, and #10) completed annual training and competencies related to the provision of care and services for five insulin dependent Residents (#48, #79, #58, #9, and #60) out of a total sample of 26 Residents. Specifically, the facility failed to:

1.Notify the physician or nurse practitioner when residents' blood glucose levels fell below parameters, or when insulin was held due to hypoglycemia.

2.Follow physician orders for when to give or hold insulin based on blood glucose levels.

Findings Include:

According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice.

Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that

an individual needs to perform work roles or occupational functions successfully.

Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies and training in areas as indicated in the facility assessment:

Medication: Awareness of any limitations of administering medications, administration of medications that residents need, by route; oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic, etc. Assessment/management of polypharmacy.

Management of Medical Conditions: Assessment, early in identification of problem/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD), gastroenteritis, infections such as UTI and gastroenteritis, pneumonia, hypothyroidism.

According to Management of Diabetes and Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association (February 2016), several organizations have developed diabetes guidelines for patients living in long term care settings. Almost all of these guidelines emphasize the need to individualize care goals and treatments related to diabetes, the need to avoid sliding scale insulin (SSI) as a primary means of regulating blood glucose, and the importance of providing adequate training and protocols to long term care staff who may be operating without the presence of a practitioner for prolonged periods.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Review of the facility policy titled, Employee Compliance Training and Education, last revised 2022, indicated but was not limited to the following: Level of Harm - Immediate jeopardy to resident health or -Milltown Health and Rehabilitation as part of its continued commitment to compliance with legal safety requirements, shall conduct initial employment training and mandatory annual compliance program and policy education and training for all employees. The facility also conducts mandatory periodic specific Residents Affected - Some education and training. The facility employee attendance and participation in training programs is a condition of continued employment and failure to comply with training requirements will result in disciplinary action up to and including termination of employment.

-Attendance at educational and training sessions is the responsibility of each employee and will be documented by the Compliance Officer.

Review of the Milltown Health and Rehab Facility Assessment Tool, undated, indicated the following:

Staff training/education and competencies:

2.Services and Care We Offer Based on our Residents ' Needs:

Management of Medical Conditions:

-Assessment.

-Early identification of problems disorientation.

-Management of medical and psychiatric symptoms.

-Conditions such as heart failure.

-Diabetes.

-Chronic Obstructive Pulmonary Disease (COPD)

-Gastroenteritis, infections such as UTI.

-Pneumonia.

-Hypothyroidism.

Medications:

-Awareness of any limitations of administering.

-Medications.

-Administration of Medication that residents need.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 -By route: oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic, etc. Level of Harm - Immediate jeopardy to resident health or 3.4 Describe the staff training/education and competencies that are necessary to provide the level and types safety of support and care needed for your resident population. Include staff certification requirements as applicable. Potential data sources include hiring, education training competency instructions and testing Residents Affected - Some policies. Some examples of annual clinical competencies include but are not limited to the following:

-Person centered care.

-Infection Control.

-Medication administration.

-Resident assessments.

-Measurements (e.g., BP (blood pressure), wt (weight), etc.

-Specialized services (e.g., colostomy care, etc.).

Resident #9 was admitted to the facility in October 2022, with diagnoses that included type II diabetes mellitus, hypertension, and dementia.

Review of the medical record indicated on 5/14/24, 5/17/24, 5/27/24, and 6/2/24 Nurse #5 and Nurse #6 failed to follow the physician ' s order and incorrectly administered insulin glargine when blood glucose levels were less than 150mg/dl. Additionally, on 5/13/24, 5/30/24 and 6/4/24 Nurse #5 failed to follow the physician ' s order, the hypoglycemic protocol and notify the physician for treatment of blood glucose levels less than 70 mg/dl.

Resident #79 was admitted to the facility in August 2023, with diagnoses that included type II diabetes mellitus, renal failure, hypertension, and dementia.

Review of Resident #79 ' s Medication Administration Record (MAR) dated March 2024 indicated that on 3/21/24 his/her blood glucose was 15 (severely low). There was no indication on the MAR or progress notes that nursing staff followed the physician ' s orders, initiated the hypoglycemic protocol, or notified the physician regarding Resident #79 ' s severely low blood glucose level.

During an interview on 6/17/24 at approximately 2:10 P.M., Nurse #10, said the entry on Resident #79's MAR dated 3/21/24 of 15 must have been a typo. Nurse #10 said that if Resident #79's blood sugar was 15

she would have initiated the hypoglycemic protocol and notified the physician.

Resident #48 was admitted to the facility in March 2024, with diagnoses that included diabetes, hypertension, and cerebral vascular accident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Review of Resident #48's MAR dated May 2024 indicated that on 5/6/24 at approximately 4:00 P.M., his/her blood glucose level was 19 (severely low). The MAR and progress notes failed to indicate Nurse #12 initiated Level of Harm - Immediate the hypoglycemic protocol or notify the physician regarding the Resident's severely low blood glucose level. jeopardy to resident health or The code on the MAR (#9) indicated see progress notes. Review of the 5/6/24 nursing progress notes did safety not reference the blood glucose level of 18, or initiating the hypoglycemic protocol, or notifying the physician.

Residents Affected - Some During an interview on 6/17/24 at approximately 1:10 P.M., Nurse #12 said the entry on Resident #48's MAR dated 5/6/24 of 19 must have been a typo. Nurse #12 said that if Resident #48's blood sugar was 19 she would have initiated the hypoglycemic protocol and notified the physician.

Resident #58 was admitted to the facility in December 2023, with diagnoses that included diabetes and hypertension.

Review of Resident #58's MAR dated April 2024 indicated that on 4/8/24 at approximately 11:00 A.M., his/her blood glucose level was 67, and on 4/9/24 at approximately 11:00 A.M. the blood glucose level was 66. The MAR and progress notes failed to indicate nursing staff initiated the hypoglycemic protocol or notify

the physician regarding the Resident's low blood glucose level.

On 6/17/24 at approximately 2:00 P.M., the surveyor attempted to contact Nurse #11 regarding Resident #58's blood glucose level on 4/8/24 of 67, and his/her blood glucose level of 66 on 4/9/24. Nurse #11 did not respond to voicemail messages or texts.

Resident #60 was admitted to the facility in October 2023 with diagnoses that include type II diabetes, dementia, and obesity.

Review of the medical record indicated on 4/2/4/24, 5/2/24, 5/6/24, 5/12/24, 5/22/24, 5/23/24, 5/24/24, 5/29/24, 6/4/24, and 6/17/24 Resident #60 ' s scheduled Humalog insulin was held. The progress notes failed to indicate that a Physician or Nurse Practitioner was notified that the medication was not administered.

During an interview on 6/17/24 at 12:41 P.M., Nurse #1 said that he was assigned to care for Resident #60.

He said that before breakfast Resident #60 had a blood sugar of 111, so he held his/her 3 units of Humalog insulin. Nurse #1 further said that he did not notify the Physician or NP that the medication was held. Nurse #1 said that a Physician or NP should be notified if a medication is held either due to parameters or nursing judgement and that it should be documented in a progress note.

The Director of Nursing provided the surveyor with the education files for thirteen nurses. Review of the education records for three of thirteen licensed nurses failed to indicate that annual competencies for medication administration, specifically for insulin dependent residents, were completed in 2023 or thus far in 2024 for Nurse #5, #6, and #10.

During an interview on 6/18/24 at 11:32 A.M., the Director of Nursing said the facility holds two annual competency fairs and it would be the expectation that all nursing competencies would be completed yearly to ensure all staff are competent in the care they provide.

The Director of Nursing was unable to provide annual competency documentation for Nurse #5, #6 and #10 by the conclusion of survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49880

Residents Affected - Few Based on record review, policy review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for one Resident (#81) out of a total sample of 26 Residents.

Findings Include:

Review of facility policy titled Drug Regimen Review, dated as effective 6/2022, indicated:

-The consultant Pharmacist reviews the medication regimen of each active resident at least monthly. Findings and recommendations are reported to the Director of Nursing and the Medical Director.

-3. The consultant Pharmacist documents potential or actual medication therapy problem and communicate them to the responsible prescriber, unit manager and the Director of Nursing (DON) and the Medical Director. [sic]

-4. The consultant Pharmacist documents all potential or actual significant nursing documentation problems found relating to medications and communicates them in writing to the DON and Medical Director.

Resident #81 was admitted to the facility on [DATE REDACTED] with diagnoses that include depression, adult failure to thrive and mood disorder.

Review of Resident #81's most recent Minimum Data Set (MDS) assessment, dated 4/17/24, indicated a Brief Interview for Mental Status exam score of 7 out of a possible 15 indicating that Resident #81 has severe cognitive impairment. The MDS further indicated that the Resident takes an antipsychotic medication.

Review of Resident #81's current physician orders indicated the following:

-Risperdal (an antipsychotic medication) 1 milligram (mg) by mouth in the morning for unspecified dementia, unspecified severity, with other behavioral disturbance, dated as updated 5/8/24.

-Risperdal 0.5 mg by mouth at bed time for unspecified dementia, unspecified severity, with other behavioral disturbances, dated as updated 5/8/24.

Review of Consultant Pharmacist Recommendation forms provided to surveyor indicated the following:

-On 1/15/24: The Resident is receiving the antipsychotic medication Risperdal to treat dementia without behavioral disturbance. Please clarify this diagnosis in PCC (Point Click Care, a medical records program).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 -On 2/25/24: The Resident is receiving the antipsychotic medication Risperdal to treat dementia without behavioral disturbance. Please clarify this diagnosis in PCC (currently says unspecified mood) Level of Harm - Minimal harm or potential for actual harm -On 3/20/24: The Resident is receiving the antipsychotic medication Risperdal to treat dementia without behavioral disturbance. Residents Affected - Few -On 4/16/24: The Resident is receiving the antipsychotic agent Risperdal- but lacks an allowable diagnosis to support its use.

The 4/16/24 recommendation has a physician's signature dated 5/8/24 with recommendations from the physician to Add Dx [diagnosis] of Hallucinations/ psychosis with dementia

Review of the medical record indicated that the facility failed to enter the recommended diagnosis into the medical record.

Review of the medical record indicated that on 5/8/24 the diagnosis Unspecified dementia, unspecified severity, with behavioral disturbance was added to the medical record of Resident #81.

During an interview on 6/18/24 at 7:57 A.M., Nurse Unit Manager (#1) said that her process for managing MMRs completed by the consultant Pharmacist is to separate them by provider and place them in the physician communication books to be addressed. Once signed off by the Physician or Nurse Practitioner, either she or another staff nurse will institute the recommendations or orders. Nurse Unit Manager #1 said that their was a period of time that interim physicians were covering the facility and they would not sign off on

the pharmacy recommendations.

During an interview on 6/18/24 at 9:27 A.M., the Director of Nurses (DON) said that once the monthly consultant Pharmacist recommendations are completed they are emailed to the facility and dispersed to the appropriate units. The DON said that he would expect that within 7-10 days the recommendations are addressed and put into place and that the pharmacy recommendations for Resident #81 were not addressed timely or appropriately. The DON said that he was not aware physicians were not willing to address recommendations during a period of interim physician and Nurse Practitioner coverage in the facility, and if

he knew he would have addressed it with them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 45763

Residents Affected - Some Based on observation, policy review and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled, and that dented cans of food were not stored with usable cans.

Findings include:

Review of the facility's policy titled Dietary - Food Storage, dated February 2022, indicated the following:

-It is the policy that storage of all food items will be stored in a sanitary environment and all food purchased will be stored in accordance with required temperatures and storage areas.

-Any bulging, leaking, or dented cans which indicates food spoilage are not to be used and removed from the storage area. (sic.)

-Prepared foods shall be kept covered, labeled with contents and dated.

On 6/10/24 at 7:56 A.M., the surveyor made the following observations during the initial walkthrough of the kitchen:

-A significantly dented can of ready-to-eat peppers on the can-rack in the dry-storage area.

-A package of salami, opened, wrapped, but undated in the walk-in refrigerator.

-A package of deli meat, wrapped and dated 5/12 in the walk-in refrigerator. The deli meat appeared pale, and had a pungent odor consistent with decay.

-A package of deli meat, wrapped but unlabeled and undated in the walk-in refrigerator.

-A package of deli meat wrapped, labeled turkey and dated 5/29 in the walk-in refrigerator.

-A container labeled egg salad, wrapped and dated 6/5 in the walk-in refrigerator.

-A gallon of milk, opened but undated in the walk-in refrigerator.

-A bottle of orange juice, opened but undated in the walk-in refrigerator

On 6/10/24 at 8:45 A.M., the surveyor made the following observations in the refrigerator of the third-floor unit:

-Two bottles of orange juice, opened but undated.

-A bottle of milk, opened but undated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 6/10/24 at 9:00 A.M., the surveyor made the following observations in the refrigerator of the second-floor unit: Level of Harm - Minimal harm or potential for actual harm -A bottle of apple juice, opened but unlabeled.

Residents Affected - Some -A bottle of cranberry juice, opened but undated.

-A bottle of orange juice, opened but undated.

-A bottle of milk, opened but undated.

During an interview on 6/10/24 at 8:52 A.M., Nurse (#2) said all drinks stored in the unit refrigerators should be dated once opened.

During an interview on 6/10/24 at 8:10 A.M., the Food Service Director (FSD) said all prepared and opened food and drinks, including milk, must be labeled and dated. The FSD said mayonnaise- based salads should be discarded after three days, and deli meat should be discarded seven days after opening. The FSD said cans of food must be checked when received and dented cans should not be placed on the rack, instead

they should be set aside in his office to be returned to the vendor. The FSD also said that in addition to being checked when received, the can rack is checked every Monday for dented cans. The FSD said the can of peppers should not have been on the can rack. The FSD also said that the deli meats and egg salad should have been discarded.

During an observation and follow-up interview on 6/11/24 at 7:33 A.M., the surveyor observed a significantly dented can of cranberry sauce on the can-rack in the dry-storage area. The FSD said the dented can of cranberry sauce must have been missed during Mondays weekly can check and must be set aside for the vendor. The FSD said juices should be dated when opened and discarded two days after they were opened.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 Provide or get specialized rehabilitative services as required for a resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45763 potential for actual harm Based on observation, interview, and record review the facility failed to provide rehabilitation services for one Residents Affected - Few Resident (#53) out of a total sample of 26 residents. Specifically, the facility failed to evaluate a Resident's hand after a hand splint in place for limited range of motion was discontinued due to Resident refusals, and

after the Nurse Practitioner documented that she was concerned about Resident #53's nails digging into his/her palm due to a possible hand contracture.

Findings include:

Review of the facility policy, titled Rehabilitation screen/referral - guideline, dated December 2023, indicated

the following:

-To screen the resident's functional and clinical status, determine the need for skilled rehabilitation intervention and/or to address problem-specific issues, rehabilitation screening and referrals may be requested, from nursing, therapy, family member and/or caregivers. The rehabilitation screen and referral form will be utilized as a communication tool between nursing and rehab for changes in the residents' status warranting a screening to determine if further assessment and or intervention is warranted as well as recommendations and clarification for resident's needs.

-The rehabilitation screen is a brief professional review of the resident by observation, review of the medical record, interview of the resident, facility staff or family member. This does not require a physician's order.

This is not a billable service, however, a referral to therapy may result directly in an evaluation and a screen may not be indicated. If further assessment is indicated during the screening process, then an evaluation is necessary.

-A member of the rehabilitation team (registered and/or assistant) will complete the rehabilitation referral/screen to ensure clinically appropriate rehab services are provided to all residents. Screening information should be gathered through chart review, consultation with nursing, resident interview.

-Upon review, the appropriate therapy discipline will make the determination if a comprehensive evaluation is indicated. This will be documented in the screening/referral form.

-After the screen is completed, the resident will receive recommendations for skilled rehab services, or a follow up from nursing via the rehabilitation and screening and referral form. Therapist will sign and date upon completion of screen form.

-Rehabilitation manager will review the screen outcome and assess for any further need or follow up with the therapist and/or nursing.

-If it is determined that the resident can benefit from a comprehensive evaluation, the clinician will proceed with the evaluation request per facility procedures.

Resident #53 was admitted to the facility in April 2021 with diagnoses including stroke and hemiparesis (a medical condition that causes weakness on one side of the body).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 Review of the most recent Minimum Data Set (MDS) assessment, dated 3/26/24, indicated that Resident #53 was unable to complete a Brief Interview for Mental Status exam as the Resident was rarely/never Level of Harm - Minimal harm or understood. The MDS further indicated that Resident #53 had impairment of range of motion on one side potential for actual harm impacting both the upper and lower extremity.

Residents Affected - Few On 6/10/24 at 9:17 A.M., the surveyor observed Resident #53 in his/her room. Resident #53's right hand was tightly closed, and the Resident was not wearing a splint.

Review of Resident #53's care plans indicated the following:

The resident had a cerebral vascular accident (CVA/stroke) affecting; Right Hemiparesis, Swallowing Issues, Falls, Receptive and Expressive Aphasia, with the following intervention:

-Monitor/document mobility status. If resident is presenting with problems or paralysis, obtain order for Physical Therapy and Occupational therapy to evaluate and treat.

-The resident has potential for pressure ulcer development related to incontinence, limited mobility, HTN (hypertension), PAD (peripheral artery disease), [NAME] (a pressure sore risk evaluation scale) score less than 15, CVA with left hemi (hemiparesis) refused to wear splint OT gave her.

-Resident refused to wear the black wrist and finger splint given to her by OT (occupational therapy), initiated 7/7/23

-The resident has potential for pressure ulcer development.

-The resident requires hand splints, initiated 8/1/23.

Review of Resident #53's OT (Occupational Therapy) Discharge Summary, dated 5/4/23, indicated the following goals:

Short term goal #1.0 - met on 5/9/23.

Patient will tolerate wearing splint/orthotic 70 percent of the recommended scheduled time daily, discharge (5/9/23) good tolerance to wearing his/her splint.

Short term goal #2.0 - met on 5/9/23.

OT to complete written instructions for caregivers and patient to follow for wearing schedule/how to don and doff orthotic right wrist, discharge (5/9/23) caregivers nursing managers are carrying over the recommended orthotic wearing schedule.

Review of the OT readmission screening form, dated 10/14/23, indicated that Resident #53 did not have a change in condition or safety status, a need to modify or create a functional maintenance program, or a potential for the Resident to decline further without intervention. The readmission screening form indicated that therapy evaluation was not indicated.

Review of Resident #53's physician orders indicated the following discontinued order:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 Splinting Schedule Black tone inhibition Splint OT has completed education to Nurse manager for the floor

on how to don and doff the splint /orthotic Requesting Nursing / CNA staff have the patient put on and wear Level of Harm - Minimal harm or the Black wrist and finger splint for TWO HOURS during day shift take off after two hours and check skin potential for actual harm condition, discontinued on 2/15/24.

Residents Affected - Few Further review of the physician's orders failed to indicate an active order for rehab services to evaluate Resident #53.

Review of the Nurse Practitioner's (NP) progress note, dated 5/16/24, indicated Resident #53's hand was contracted and that the Resident's nails were applying pressure to his/her palm. Further review of the progress note indicated that the NP would have orthotic evaluate Resident #53 for a hand splint.

Review of Resident #53's medical record failed to indicate the Resident was evaluated by the orthotic's service that the NP consulted.

During an interview on 6/13/24 at 8:26 A.M., the NP said that on 5/15/24 she had evaluated Resident #53 and was concerned that the Resident's hand was contracted. The NP said that she had consulted an orthotics service from outside of the facility to evaluate the Resident for a splint, the NP said she wanted something in place to keep the Resident's hand open to promote skin integrity and avoid progression of the possible contracture. The NP said that the contracted orthotics provider had come out on 5/29/24, but had not evaluated Resident #53, the NP said she became aware on the weekend following the 5/29/24 visit, that

the Resident had not been evaluated. The NP said that insurance often denied therapy services for residents admitted for long-term care so she kind of gave up placing orders for in-house therapy evaluations.

During an interview on 6/17/24 at 11:21 A.M., the Consulting Orthotic Provider said the NP consulted him to evaluate Resident #53 for a splint because she was concerned about a hand contracture. The Consulting Orthotic Provider said he had planned to see Resident #53 on 5/29 when he was in the building but that he had forgotten to do so and had not evaluated the Resident.

During an interview on 6/13/24 at 8:19 A.M., Nurse #2 said that if the NP had a concern about limited range of motion and made a recommendation for a resident to be evaluated by rehabilitation services that an order would be placed, and that this would be communicated to the rehabilitation department.

During an interview on 6/13/24 at 8:52 A.M., the Director of Rehab Services (DOR) said residents were screened for the need for rehabilitation services quarterly, and on readmission from the hospital. The DOR said therapy staff were constantly on the floor observing for resident's need of services, and that if nursing determines a resident would benefit from evaluation that they would communicate this to the rehab department. The DOR said that if the NP had a recommendation for an evaluation that the NP would place

an order; the DOR also said she reviews the NP and MD notes daily. The DOR said that if a resident who had a splint put in place began refusing/not tolerating the splint that this would prompt an OT evaluation for

the purpose of exploring an alternate method for protecting the skin and promoting the ability for staff to provide hygiene. The DOR said the NP had not reached out about her concern regarding Resident #53, and that the NP had not placed an order for evaluation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 During an interview on 6/13/24 at 9:42 A.M., the Occupational Therapist said that he had worked with Resident #53 in May of 2023 and that the Resident was discharged from therapy services with a hand splint; Level of Harm - Minimal harm or the Occupational Therapist said that at that time nursing staff was educated regarding the Resident's splint potential for actual harm and that an order was in place. The Occupational Therapist said that in order to address Resident #53's splint refusals or explore alternatives that he would need to evaluate the Resident, and that he had not Residents Affected - Few evaluated the Resident for his/her splint or splint alternative since May of 2023.

During a follow-up interview on 6/13/24 at 10:45 A.M., the Occupational Therapist said he had not been notified that Resident #53 was refusing his/her hand splint, and that there were alternatives that could be trialed for Resident #53.

During an interview on 6/13/24 at 11:03 A.M. the Regional Rehabilitation Staff said the goal would be to maintain range of motion and skin integrity and that when a resident refuses a splint that the resident should be evaluated for an alternative such as a rolled-up face cloth.

During an interview on 6/17/24 at 12:50 P.M., Unit Manager #2 said that if a resident begins refusing an orthotic device, such as a splint, that the physician and rehabilitation services must be notified promptly. Unit Manager #2 said that she would have expected whoever discontinued Resident #53's splint order to follow up with the physician and rehabilitation services. Unit Manager #2 said Resident #53's splint had been used to prevent a contracture which the Resident was at risk for due to his/her diagnosis of hemiparesis.

During a follow-up interview on 6/18/24 at 7:28 A.M., the DOR said there was not always enough staffing to cover the needs of the building, and that the screening conducted by the OT on 10/24/23 could have prompted an evaluation for the hand splint refusal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 45763

Residents Affected - Few Based on records reviewed and interviews the facility failed to ensure nursing maintained an accurate medical record for one Resident (#35) out of a sample of 26 residents. Specifically, for Resident #35 nursing documented they obtained blood pressure from his/her right arm when they did not.

Findings include:

Resident #35 was admitted to the facility in January 2024 with a diagnosis of end stage renal disease.

Review of the most recent Minimum Data Set (MDS) assessment, dated 3/26/24, indicated that Resident #35 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating Resident #35 had moderate cognitive impairment. The MDS further indicated Resident #35 received dialysis treatment.

Review of Resident #35's active physician orders indicated the Resident had a fistula in his/her right arm.

Review of Resident #35's care plans indicated the Resident received Hemodialysis three times a week and had a right arm fistula with the following intervention:

-Do not draw blood or take blood pressure in arm with graft.

On 6/10/24 at 9:17 A.M., the surveyor observed a sign above Resident #35's bed indicating that blood draws and blood pressure readings should not be taken from his/her right arm.

Review of Resident #35's blood pressure readings indicated nursing obtained his/her blood pressure using his/her right arm on the following dates: 3/25/24, 4/3/24, 4/5/24, 4/8/24, 4/14/24, 4/17/24, 4/19/24, 4/22/24, 4/24/24, 4/26/24, 4/28/24, 4/29/24, 5/1/24, 5/3/24, 5/10/24, 5/13/24, 5/15/24, 5/17/24, 5/19/24, 5/20/24, 5/22/24, 5/25/24, 5/29/24, 5/31/24, 6/2/24, 6/3/24, 6/9/24, 6/12/24, 6/16/24.

During an interview on 6/11/24 at 8:45 A.M., Resident #35 said staff never take blood pressure readings from his/her right arm, and that staff only use his/her left arm for blood pressure readings.

During an interview on 6/11/24 at 11:23 A.M., Nurse Unit Manager (#1) said that Resident #35's right arm was not used for blood pressure readings, and that she had documented that she measured the blood pressure using the right arm in error.

During an interview on 6/11/24 at 11:30 A.M., Nurse (#2) said blood pressure readings should not be taken using Resident #35's right arm and that she had documented that the readings were taken using the right arm in error.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 56 225318 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225318 B. Wing 06/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill Town Health and Rehabilitation 22 Maple Street Amesbury, MA 01913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During an interview on 6/12/24 at 7:23 A.M., Nurse (#3) said blood pressure readings were not taken from Resident #35's right arm, and that she had documented that the readings were taken from the right arm in Level of Harm - Minimal harm or error. potential for actual harm

During an interview on 6/11/24 at 11:33 A.M., The Director of Nursing (DON) said his expectation was that Residents Affected - Few nurses accurately document which arm the blood pressure was taken from, and that documentation should reflect exactly what was completed by nursing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 56 225318