Apple Valley Center

F-F725 during the survey completed on 03/05/24, and the Facility's Plan of Correction, with an alleged compliance date of 03/25/24, indicated the following:

-The Director of Nurses (DON) educated staff that meal tray service must be performed upon receipt of the meal carts from the kitchen to ensure food remained at the appropriate temperature.

-The DON would audit staff to resident staffing ratios weekly for four weeks then monthly for three months to ensure nursing care was provided to all residents in accordance with their care plans.

-The results of the audits would be presented to the Quality Assurance Performance Improvement (QAPI) committee until substantial compliance had been achieved.

During a telephone interview on 06/04/24 at 11:16 A.M., Resident #1's Family Member said that on 05/17/24 at 3:53 P.M. and 5/19/24 at 1:24 P.M., she found Resident #1 in bed with a top sheet, blanket, and hospital gown that were wet from urine and diarrhea. The Family Member said that Resident #1 had to wait for care by staff on both days because she was told by nursing they were short staffed.

During a telephone interview on 06/11/24 at 10:28 A.M., Nurse #2 said they were supposed to have four CNAs on the evening shift, but lately they had only three and sometimes only two CNAs on duty for the evening shift. Nurse #2 said staffing was bad, especially for CNAs.

During an interview on 06/05/24 at 12:47 P.M. and 2:56 P.M., Certified Nurse Aide (CNA) #1 said they were supposed to have four CNAs on the day shift, and when they had two CNAs they could not provide incontinent care to each resident every two hours, and that even when there were three CNAs it can be difficult to get to each resident.

During a telephone interview on 06/07/24 at 12:02 P.M., Nurse #1 said it was a real struggle when they had two CNAs, by the time the CNAs got through their first rounds on each resident, stopped care during mealtimes, it was late in the day when they started their second rounds. Nurse #1 said the CNAs are drowning when there are only two of them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 225421 Department of Health & Human Services Printed: 09/24/2025 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 225421 B. Wing 06/05/2024

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

Ayer Valley Rehab and Nursing 400 Groton Road Ayer, MA 01432

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 0867 On 06/05/24, from 8:25 A.M. through 9:03 A.M., the surveyor observed the breakfast meal pass on North 2 Unit which took over 45 minutes to complete. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/05/24 at 12:47 P.M., Certified Nurse Aide (CNA) #1 said that there were supposed to be four CNAs but that day they had three and that meant that each CNA had 13 residents and one had 14 Residents Affected - Some residents to care for. CNA #1 said that because it was a secured unit, a lot of the residents had behaviors and many of them required assistance of two staff members for care. CNA #1 said it was difficult to get residents up, pass the breakfast trays, and feed the residents who needed to be fed, all at once.

During an interview on 06/05/24 at 1:27 P.M. Certified Nurse Aide (CNA) #2 said there were supposed to be four CNAs on but usually they only had three. CNA #2 said they were supposed to stop giving resident care at 8:00 A.M. so they can start the breakfast pass but that did not always happen. CNA #2 said they were usually done passing breakfast trays by 9:00 A.M. (approximately one hour after the meal trucks scheduled time of arrival).

During an interview on 06/05/24 at 3:41 P.M. the Director of Nurses (DON) said it was her expectation that a meal pass should not take more than 10-15 minutes to complete.

Review of the Facility Assessment, dated 02/26/24, indicated the Facility was licensed for 123 beds and there were 41 beds on the North 2 Unit. The Assessment indicated the Facility required the following for Full Time Employees (FTE):

-Certified Nurse Aides (CNA)- 29

-Licensed Practical Nurse (LPN)- 19

-Registered Nurse (RN)- 8

Review of the Nursing Staff List indicated the Facility employed 11 FTE CNAs (18 less than the Facility Assessment indicated) and four FTE RNs (4 less than the Facility Assessment indicated).

During an interview on 06/05/24 at 2:26 P.M., the Schedule Coordinator said the staffing goals on the secured North 2 Unit were as follows:

-7:00 A.M. through 3:00 P.M. (day) shift - four CNAs and one Nurse

-3:00 P.M. through 11:00 P.M. (evening) shift- four CNAs and one Nurse

-11:00 P.M. through 7:00 A.M. (night) shift- two CNAs and one Nurse

-8:00 A.M. through 8:00 P.M. shift- one additional Nurse

The Schedule Coordinator said she did not consider a unit to be short staffed unless there was only one CNA on duty.

Review of the Nursing Staffing Schedules for North 2 Unit from 05/05/24 through 06/05/24 indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 225421 Department of Health & Human Services Printed: 09/24/2025 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 225421 B. Wing 06/05/2024

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

Ayer Valley Rehab and Nursing 400 Groton Road Ayer, MA 01432

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 0867 On the following dates, the Facility did not have four CNAs scheduled to work on the day shift:

Level of Harm - Minimal harm or - 05/05/24 through 05/08/24, potential for actual harm - 5/10/24 through 05/14/24, Residents Affected - Some - 05/17/24 through 05/19/24,

- 05/24/24, 05/25/24, 05/27/24, 05/28/24, and 05/29/24,

- 06/02/24, 06/03/24, 06/05/24

On the following dated, the Facility did not have four CNAs scheduled to work on the evening shift:

- 05/05/24, 05/06/24, 05/11/24, 05/13/24, 05/17/24, 05/18/24, 05/19/24,

- 05/21/24 through 05/26/24, and 05/28/24,

- 05/30/24 through 06/05/24.

During an interview on 06/05/24 at 3:59 P.M., the Administrator said that staffing had been an ongoing issue and that they supplemented with Agency staff but they were still having a lot of call outs. The Administrator said the meals should be put in front of the residents within five minutes of truck delivery.

The Administrator said that none of the staff to resident ratio audits for May 2024 had been done, as indicated in the Facility's Plan of Correction (03/25/24).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 225421