North End Rehabilitation And Healthcare Center

F-F726.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36797

Residents Affected - Some Based on observation, record review and interview, the facility failed to ensure nursing staff adhered to professional standards of practice for the administration of free water flushes and enteral tube feeding (water and nutrition taken through a tube directly into the stomach) for six out of seven Residents (#18, #40, #67, #71, #72 and #73) with a tube feed observed. Specifically:

1. For Resident #18, the facility failed to label and date the enteral free water administration bag.

2. For Resident #40, the facility failed to label and date the water administration bag and failed to ensure the amount of tube feeding administered followed the physician's order.

3. For Resident #67, the facility failed to label the tube feeding bottle and the free water administration bag with the date and time hung.

4. For Resident #71, the facility failed to label the free water administration bag with the date hung and failed to ensure the amount of tube feed administered followed the physician's order

5. For Resident #72, the facility failed to label the free water administration bag with the date hung.

6. For Resident #73, the facility failed to label the free water administration bag with the date hung and failed to ensure the amount of tube feed administered followed the physician's order.

Findings include:

Review of the facility policy titled Enteral Nutrition, revised November 2018, indicated adequate nutrition support through enteral nutrition is provided to residents as ordered.

Review of the facility policy titled Enteral Feedings-Safety Precautions, revised November 2018, indicated that feed formulas are to be discarded 48 hours after opening. Further review failed to indicate that tube feedings and free water administration bags are to be labeled and dated.

1. Resident #18 was admitted to the facility in March 2025 with diagnoses including protein-calorie malnutrition, dependence on ventilator, and muscle wasting and atrophy.

Review of the Minimum Data Set assessment dated [DATE REDACTED], indicated that Resident #18 was moderately cognitively impaired and totally dependent of staff for all activities of daily living. Further review indicated that Resident #18 received 51% or more of their nutrition through the use of a feeding tube.

Review of the current care plan indicated a focus of enteral tube feeding due to dysphagia with an intervention to administer tube feeding as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 0693 Review of the physician's orders dated May 2025 indicated an order for free water flushes of 200 ml (milliliters) every six hours every shift. Level of Harm - Minimal harm or potential for actual harm On 5/4/25 at 8:30 A.M., the surveyor observed that the water bag, instilling free water into the enteral tube, was not labeled with the date hung. Residents Affected - Some 2. Resident #40 was admitted to the facility in February 2024 with diagnoses including protein-calorie malnutrition, dysphagia, and dependence on ventilator.

Review of the Minimum Data Set assessment, dated 2/27/25, indicated that Resident #40 was severely cognitively impaired and totally dependent on staff for all activities of daily living. Further review indicated that Resident #40 received 51% or more of their nutrition through the use of a feeding tube.

Review of the physician's orders indicated the following: every shift for nutrition Vital AF 1.2 @ 55 ml/hr (milliliters per hour), may use peptaman 1.5 until vital available. Further review indicated the following order: Enteral Feed order every 6 hours for hydration additional FWF (free water flush) of 200 ml q6h (every 6 hours).

Review of the current care plan indicated a focus of enteral tube feeding due to dysphagia with an intervention to administer tube feeding as ordered.

Review of the dietician's note dated 2/27/25 indicated the following: Note Text: TF (tube feed) reviewed. Rt (resident) currently on continuous feed of vital AF 1.2 @ 55 ml/hr w/additional FWF of 200 ml q6h (every 6 hours). This current regimen provides a total daily volume of 1320 ml, 1584 kcal, 99g pro (grams protein), 1871 ml fluid, meeting 100% of goal needs. No s/s/x (signs or symptoms) of intolerance noted. Wt (weight) reviewed. Unable to assess wt trend, last wt taken on 11/21/24. Rt (resident) known to refuse wt. Encourage obtaining wt as able to monitor accurate wt trend. Skin remains intact. Labs and meds reviewed. Recent lab notable for abnormally low creatinine. Continue current nutritional care plan and intervention. Continue to monitor.

On 5/4/25 at 8:15 A.M., the surveyor observed a 1500 ml tube feed bottle hung, dated 5/2/25, and running at @ 55 ml/hr (milliliters per hour) with the label indicating the feed was started at 1800 (6 P.M.). The surveyor observed that the amount left in bottle was 300 ml. The surveyor also observed that the water bag was not labeled with the date hung.

At a rate of 55 ml/hr for 38 hours the amount instilled should have been 2090 ml and not the 1200 ml as indicated on the bottle.

3. Resident #67 was admitted to the facility in September 2023 with diagnoses including protein-calorie malnutrition, dysphagia and Alzheimer's disease.

Review of the Minimum Data Set assessment dated [DATE REDACTED], indicated that Resident #67 was severely cognitively impaired and substantially to totally dependent on staff for all activities of daily living. Further

review indicated that Resident #67 received 51% or more of their nutrition through the use of a feeding tube.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 0693 Review of the physician's orders dated May 2025 indicated the following: every shift for Nutrition Continuous feed of Glucerna 1.0 @ 75 ml (total daily volume of 1800 ml) via J-tube. Further review indicated an order for Level of Harm - Minimal harm or free water flushes of 75 ml every 4 hours via J-tube (a tube directly inserted into the jejunum for the purpose potential for actual harm of administering nutrition).

Residents Affected - Some On 5/4/25 at 8:11 A.M., the surveyor observed Resident #67 lying in bed with an enteral tube feeding bottle and enteral water administration bag hanging at bedside. The surveyor observed the tube feed running at 75 ml (milliliters) per hour. The surveyor also observed that the tube feeding bottle, and the free water administration bag were not labeled with the date and time hung.

4. Resident #71 was admitted to the facility in January 2025 with diagnoses including protein-calorie malnutrition, dysphagia, and Guillain-Barre Syndrome.

Review of the Minimum Data Set assessment dated [DATE REDACTED], indicated that Resident #71 was severely cognitively impaired as evidenced by a score of 7 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #71 was substantially/dependent on staff for all activities of daily living. Further review indicated that Resident #71 received 51% or more of their nutrition through the use of a feeding tube.

Review of the physician's orders dated May 2025 indicated the following order: Enteral: Glucerna 1.2 Cal liquid via feeding tube every shift, feeding pump set at 65 ml/hr (milliliters per hour) for 24 hours, total volume 1560 ml. Further review indicated an order for free water flushes of 200 ml every 4 hours.

On 5/4/25 at 7:50 A.M., the surveyor observed Resident #71 lying in bed with a 1500 ml tube feed bottle with

a time stamp of 1900 hours (7 P.M.), hanging and running at 65 ml/hr (milliliters per hour). The surveyor also observed the tube feed bottle to be dated 5/2/25 with 1000 ml left in the 1500 ml bottle. Based on the date and volume left in the bottle the amount that should have been instilled from 5/2/25 at 7 P.M. through 5/4/25 at 7:50 A.M. is 2405 ml and not the 500 ml indicated on the tube feed bottle. The surveyor also observed that

the free water administration bag was not dated.

5. Resident #72 was admitted to the facility in November 2024 with diagnoses including protein-calorie malnutrition, dysphagia, and amytrophic lateral sclerosis.

Review of the Minimum Data Set assessment dated [DATE REDACTED], indicated that Resident #72 cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #72 was totally dependent on staff for all activities of daily living. Further review indicated that Resident #72 received 51% or more of their nutrition through the use of a feeding tube.

Review of the physician's orders dated May 2025 indicated the following order: Enteral Feed Order: Jevity 1. 5 liquid via feeding tube hung up at 9 P.M. and take down at 6 P.M., via feeding pump set at 65 ml/hr (milliliters per hour) for 18 hours, total volume 1170 ml.

Further review indicated an order for free water flushes of 150 ml every 4 hours.

On 5/4/25 at 8:24 A.M., the surveyor observed that the free water administration bag was not dated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 0693 6. Resident #73 was admitted to the facility in June 2024 with diagnoses including severe protein-calorie malnutrition, dysphagia and amytrophic lateral sclerosis. Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Data Set assessment dated [DATE REDACTED], indicated that Resident #73 was severely cognitively impaired. Further review indicated that Resident #73 was totally dependent on staff for all Residents Affected - Some activities of daily living. Further review indicated that Resident #73 received 51% or more of their nutrition through the use of a feeding tube.

Review of the physician's orders dated May 2025 indicated the following order: every shift Enteral: Osmolite 1.5 Cal liquid via feeding tube every shift, feeding pump set at 60 ml/hr for 21 hours.

On 5/4/25 at 8:32 A.M., the surveyor observed the tube feed free water administration bag was not labeled with the date hung. The surveyor also observed an enteral feed running at 60 ml/hr, the tube feed bottle was dated 5/2/25, with a time stamp of hung up at 1800 (6 P.M.). The tube feed bottle had 350 ml left in it. At 60 ml/hr for a total of 35 hours, 2100 ml should have been instilled, not 1150 ml as was indicated by what was left in the bottle.

During an interview on 5/5/25 at 8:16 A.M., the Director of Nursing (DON) said all enteral free water administration bags and tube feeding bottles should be labeled with the date and time hung as well as the prescribed rate of flow. The DON also said that the nurses should be checking to make sure that the prescribed amount to be instilled over a specific period of time was administered as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36797 potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure staff provided the Residents Affected - Few necessary care and services in accordance with professional standards of practice for two Residents (#47 and #71), out of a total sample of six residents on a ventilator.

Findings include:

Review of the facility policy titled Departmental (Respiratory therapy)-Prevention of Infection, dated revised November 2011, indicated to change respiratory tubing every seven (7) days, or as needed.

1. Resident #47 was admitted to the facility in April 2025 with diagnoses including respiratory failure, paraplegia and protein-calorie malnutrition.

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident #47 has severe cognitive impairment and was unable to complete the Brief Interview for Mental Status exam. Further review indicated that Resident #47 requires total dependence on staff for all activities of daily living and receives a high concentration of oxygen via a tracheostomy mask.

On 5/4/25 at 8:15 A.M., the surveyor observed Resident #47 lying in bed receiving humidified oxygen via a trach (tracheostomy) collar. The surveyor also observed that the trach tubing was dated 4/13/25.

Review of the physician's orders dated May 2025 indicated an order for Humidified Air via Trach Collar at 35% continuously every shift. Further review failed to indicate an order for when the trach tubing via trach collar is to be changed.

During an interview on 5/4/25 at 8:24 A.M., Respiratory Therapist #1 said the Respiratory Therapist changes all ventilator tubing every Sunday.

During an interview on 5/5/25 at 3:47 P.M., the Director of Nursing said that all respiratory tubing connected to a trach or vent is to be changed according to the physician's orders. If there are no physician's order, then

the tubing would be changed weekly per facility policy. She then said that all respiratory tubing should have a physician's order in place for frequency of tubing changes.

2. Resident #71 was admitted to the facility in January 2025 with diagnoses including protein-calorie malnutrition, dysphagia, and Guillain-Barre Syndrome.

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated that Resident #71 was severely cognitively impaired, as evidenced by a score of 7 out of 15 on the Brief Interview for Mental Stats exam. Further review indicated that Resident #71 was substantially/dependent on staff for all activities of daily living. Further review indicated that Resident #71 was on a ventilator.

On 5/4/25 at 8:17 A.M., the surveyor observed Resident #71 in bed on a ventilator. The surveyor also observed that the ventilator tubing was dated 4/20/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 0695 Review of the physician's orders dated May 2025 indicated an order for trach (tracheostomy) mask via cool mist at 35% continuously every shift. Further review indicated an order to change all disposable equipment Level of Harm - Minimal harm or weekly on Wednesday 11p-7a and PRN (as needed). potential for actual harm

Review of the current care plan, dated 5/1/25, indicated an intervention to keep respiratory equipment clean Residents Affected - Few and change disposable equipment per facility policy.

During an interview on 5/4/25 at 8:24 A.M., Respiratory Therapist #1 said the Respiratory Therapist changes all ventilator tubing every Sunday.

During an interview on 5/5/25 at 3:47 P.M., the Director of Nursing said that all respiratory tubing connected to a trach or vent is to be changed according to the physician's orders. If there are no physician's order, then

the tubing would be changed weekly per facility policy. She then said that all respiratory tubing should have a physician's order in place for frequency of tubing changes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41019 safety Based on record review and interview, the facility failed to ensure the assigned nurse was competent to Residents Affected - Few perform Cardiopulmonary Resuscitation (CPR) on one Resident (#89), who was a full code, after he/she was found unresponsive, out of a total sample of 26 residents.

Findings include:

Review of the current American Heart Association: CPR (cardiopulmonary resuscitation) and First Aide indicates that CPR - or Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest.

Review of the facility assessment indicated the following:

Staff Education and Competency: Department specific training and competencies are completed with staff throughout employment to ensure that they can safely and competently provide the levels and types of care required by our resident population .As a part of ongoing education and training, mock drills are scheduled

on a rotating shift and day schedule . The facility also implements additional staff education as a result of QAPI (Quality Assurance and Performance Improvement) actions and those incorporated in plans of correction.

Review of the facility assessment also indicated that staff are to receive annual CPR competencies and ensure that CPR certification is renewed every two years.

Review of the Minimum Data Set (MDS), dated [DATE REDACTED], indicated Resident #89 could not participate in the Brief Interview for Mental Status exam due to severely impaired cognition. Review of the MDS indicated that Resident #89 was a full code (a medical term indicating a patient's consent to receive all life saving measures).

Review of the nursing progress note, dated [DATE REDACTED], indicated the following:

At 5:00 am this nurse went into residents' room to change his/her feeding but observed that resident do [sic] not have the rising and falling of chest. This nurse touched Resident, and he/she was warm to touch but without response and no pulse. This nurse paged code blue, initiated CPR on patient and called 911. 911 arrived and took over from this nurse, on assessment, they said the patient may have expired about an house [sic] ago. The DON has been notified, so also is the family [sic]. At present, the family do not have a funeral home of choice and will notify the facility as soon as they nominate one.

During an interview on [DATE REDACTED] at 8:27 A.M., Nurse #1 said that he left Resident #89 with a CNA to go call 911 and a code blue (an overhead page indicating that emergency services are required), then retrieved the crash cart (a cart with supplies to perform life saving measures) before starting CPR on Resident #89.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 CPR certification for Nurse #1 indicated his CPR certification expired in August of 2024.

Level of Harm - Immediate Review of Nurse #1's annual competencies failed to indicate the facility ensured he completed the required jeopardy to resident health or annual CPR competency. Review of Nurse #1's CPR certification indicated his CPR certification expired in safety August of 2024, six months prior to the incident that occurred in February 2025.

Residents Affected - Few During an interview on [DATE REDACTED] at 9:27 A.M., the Director of Nursing said she did not know that Nurse #1 was not CPR certified at the time of the code. The Director of Nursing said that the facility should have made sure that Nurse #1 had renewed his CPR certification at the time of renewal.

During an interview on [DATE REDACTED] at 7:55 A.M., the Director of Nursing said that the Staff Development Coordinator (SDC) was responsible for ensuring staff competencies and CPR recertification. The Director of Nursing said that both the staff development coordinator and human resources had left and she was taking over the assigned duties of both roles. The SDC left on [DATE REDACTED] and human resources left on [DATE REDACTED]. The Director of Nursing said that the facility hadn't done any mock codes (practice codes for when a real one takes place) in the past year, as indicated in the facility assessment, and that the CPR certification is what nurses receive for their CPR competencies. The Director of Nursing said that they did another audit during survey, as part of the facility's removal plan, and identified another nurse whose CPR certification had expired.

During an interview on [DATE REDACTED] at 8:20 A.M., the Medical Director said it is his expectation that the facility and

the individual nurse ensure that their CPR certifications are renewed on time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 36797 Residents Affected - Few Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure a medication cart and treatment carts on the fourth floor were locked while a nurse was not present.

Findings include:

Review of the facility policy titled Medication Labeling and Storage, revised February 2023, indicated the following:

- The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

- Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

On 5/4/25 at 7:05 A.M., the surveyor observed a medication cart in the 4th floor hallway unlocked and without a nurse present. The surveyor opened the medication cart drawers and stood there while a certified nurse's aide walked by the surveyor and continued down the hall. The surveyor also observed another staff member sitting in a room at the end of the hall looking at the surveyor at the open medication cart. The surveyor was able to access the medication cart for 4 minutes without staff interference.

During an interview on 5/4/25 at 7:09 A.M., Nurse #6 said that she is the only one allowed access to the medication cart and it should not be open.

On 5/4/25 at 8:03 A.M., the surveyor observed a treatment cart, unlocked, next to the nurse's station on the 4th floor. The surveyor then observed the Admissions Director walking by the unlocked treatment cart multiple times without locking it. The surveyor was able to access the treatment cart without staff interference.

On 5/4/25 at 8:04 A.M., the surveyor observed a treatment cart in the hallway of the 4th floor, unlocked, without a nurse in the surrounding area. The surveyor was able to access the treatment cart without staff interference.

On 5/4/25 at 8:41 A.M., the surveyor observed a treatment cart next to the nurse's station unlocked, without

the nurse present. Multiple other staff members were around the unlocked treatment cart.

During an interview on 5/5/25 at 8:16 A.M., the Director of Nursing said that all medication carts and treatment carts are to be locked at all times when not in use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36797

Residents Affected - Few Based on observation, record review, and interview, the facility failed to maintain an accurate medical record for two Residents (#71 and #72), out of a total sample of 26 residents.

Specifically:

1. For Resident #71, the facility documented the ventilator tubing was changed when it was not.

2. For Resident #72, the facility documented the Resident recieved tube feedings at the wrong time.

1. Resident #71 was admitted to the facility in January 2025 with diagnoses including protein-calorie malnutrition, and dysphagia.

Review of the Minimum Data Set assessment dated [DATE REDACTED], indicated that Resident #71 was severely cognitively impaired, as evidenced by a score of 7 out of 15 on the Brief Interview for Mental Stats exam. Further review indicated that Resident #71 was substantially/dependent on staff for all activities of daily living. Further review indicated that Resident #71 was on a ventilator.

On 5/4/25 at 8:17 A.M., the surveyor observed Resident #71 in bed on a ventilator. The surveyor also observed that the ventilator tubing was dated 4/20/25.

Review of the physician's orders dated May 2025 indicated an order for trach (tracheostomy) mask via cool mist at 35% continuously every shift. Further review indicated an order to change all disposable equipment weekly on Wednesday 11p-7a and PRN (as needed).

Review of the current care plan, dated 5/1/25, indicated an intervention to keep respiratory equipment clean and change disposable equipment per facility policy.

Review of the facility document titled Respiratory Administration Record, dated April 2025, indicted the respiratory therapist signed, on 4/23/25 and 4/30/25, that the ventilator tubing was changed when it was not.

During an interview on 5/4/25 at 8:24 A.M., Respiratory Therapist #1 said the Respiratory Therapist changes all ventilator tubing every Sunday.

During an interview on 5/5/25 at 3:47 P.M., the Director of Nursing (DON) said that all respiratory tubing connected to a trach or vent is to be changed according to the physician's orders. The DON then said that

the respiratory therapists should not be documenting that they changed the tubing when they did not.

2. Resident #72 was admitted to the facility in November 2024 with diagnoses including protein-calorie malnutrition, dysphagia, and amytrophic lateral sclerosis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 Review of the Minimum Data Set assessment dated [DATE REDACTED], indicated that Resident #72 cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status exam. Further review indicated Level of Harm - Minimal harm or that Resident #72 was totally dependent on staff for all activities of daily living. Further review indicated that potential for actual harm Resident #72 received 51% or more of their nutrition through the use of a feeding tube.

Residents Affected - Few Review of the physician's orders dated May 2025 indicated the following conflicting orders:

1. Enteral Feed Order: Jevity 1.5 liquid via feeding tube hung up at 9 P.M. and take down at 6 P.M., via feeding pump set at 65 ml/hr (milliliters per hour) for 18 hours, total volume 1170 ml.

2. Enteral Feed Order: Jevity 1.5 liquid via feeding tube hung up at 9 A.M., and take down at 6 A.M., via feeding pump set at 65 ml/hr (milliliters per hour) for 18 hours, total volume 1170 ml.

Review of the Medication Administration Record (MAR) dated May 2025 indicated that nurses signed for both conflicting orders 5/1/25, 5/2/25, 5/3/25 and 5/4/25.

During an interview on 5/5/25 at 3:47 P.M., the Director of Nursing (DON) said that the tube feed orders were

in error and the nurses should be signing only for one time frame.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41019

Residents Affected - Few Based on record review and interview, the facility failed to implement adverse event monitoring to potentially prevent future adverse events from occurring. Specifically, one Resident (#89), who was a full code, was found unresponsive and expired and the facility failed to identify and investigate the death, as it relates to Quality Assurance and Performance Improvement (QAPI).

Findings include:

According to the U.S. Department of Health and Human Services Office of Inspector General, an adverse event is defined as the following:

An event in which care resulted in an undesirable clinical outcome-an outcome not caused by underlying disease-that prolonged the patient stay, caused permanent patient harm, required life-saving intervention, or contributed to death.

https://oig.hhs.gov/reports/featured/adverse-events/

Review of the Facility Assessment, dated [DATE REDACTED], indicated the following:

Risk Identification and Quality Assurance Performance Improvement (QAPI)

- The facility utilizes a comprehensive approach to risk identification and mitigation to ensure continous quality of care for its residents.

- The interdisciplinary team addresses both the reactive and proactive aspects of risk identification and mitigation. Resident incidents are reviewed to ensure appropriate interventions have been implemented to prevent reoccurrence. A root cause analysis is conducted to ensure causal factors have been identified and addressed.

- The QAPI committee will prioritize topics for performance improvement projects based on the current needs of the residents and our facility. Priority will be given to areas we define as high-risk to residents and staff, high- prevalence, or high-volume areas that are problem prone. Consideration of staff affected, and anticipated training needs will be reviewed prior to implementation of a performance improvement project.

Resident #89 was admitted in [DATE REDACTED] with diagnoses including chronic kidney disease, hypertension, and type 2 diabetes.

Review of the Minimum Data Set (MDS), dated [DATE REDACTED], indicated Resident #89 could not participate in the Brief Interview for Mental Status exam due to severely impaired cognition. Review of the MDS indicated that Resident #89 was a full code (a medical term indicating a patient's consent to receive all life saving measures).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 225506 Department of Health & Human Services Printed: 08/27/2025 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 225506 B. Wing 05/09/2025

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

North End Rehabilitation and Healthcare Center 70 Fulton Street Boston, MA 02109

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 [DATE REDACTED], Resident #89, who was a full code, was found unresponsive and pulseless. Nurse #1 left the Resident in the room with a certified nursing aide and proceeded to dial 911, call a code blue, then retreive Level of Harm - Minimal harm or the crash cart before initiated CPR. Nurse #1's CPR certification had expired 6 months prior to the incident. potential for actual harm

Review of the nursing progress note, dated [DATE REDACTED], written by Nurse #1, indicated the following: Residents Affected - Few At 5:00 am this nurse went into residents' room to change his/her feeding but observed that resident do [sic] not have the rising and falling of chest. This nurse touched Resident, and he/she was warm to touch but without response and no pulse. This nurse paged code blue, initiated CPR on patient and called 911. 911 arrived and took over from this nurse, on assessment, they said the patient may have expired about an house [sic] ago. The DON has been notified, so also is the family [sic]. At present, the family do not have a funeral home of choice and will notify the facility as soon as they nominate one.

During an interview on [DATE REDACTED] at 7:55 A.M., the Director of Nursing said she was unaware that Nurse #1's CPR certification had expired and that Nurse #1 should not have provided CPR. The Director of Nursing said that it was the responsibility of the Staff Development Coordinator and Human Resources to ensure staff are up to date with their certification, but that both staff had left the facility, one on [DATE REDACTED] and one on [DATE REDACTED] .

The Director of Nursing said she had taken over responsibilities of both positions until filled. The Director of Nursing said the positions had not been filled yet, but an SDC was starting soon. The Director of Nursing said that the facility had implemented a code sheet (a sheet used to record the event and timing of a code) to keep track of full code incidents in the building, but she was unsure of when they initiated the code sheets and said that sheet was never completed for the Resident that Nurse #1 performed CPR on. The Director of Nursing said that when an adverse event occurs, she will do an investigation into the event, however; the Director of Nursing said that she reviewed the notes in the electronic medical record and said that nothing stood out to her that would warrant an investigation of the situation. The Director of Nursing said she was notified of the incident, but was not aware that Nurse #1 did not start CPR immediately.

During an interview on [DATE REDACTED] at 8:33 A.M., the Administrator (at the time of the event) said when a death occurs (for someone who is a full code), the facility staff complete a code sheet and the Director of Nursing and Physician will review the code sheet, especially if the death was unexpected. The Administrator said that

the facility will typically look into an unexpected death to find out what occurred in real time. The Administrator said that the Medical Director is very involved and would help the facility look into an unexpected death. The Administrator said that in January and February, the facility did an audit of human resources and employee files to improve the process, but CPR certification was not something that was identified during that audit and it was not brought to QAPI.

During an interview on [DATE REDACTED] at 8:20 A.M., the Medical Director said that it his expectation that all staff are recertified every 2 years. The Medical Director said he remembers being notified of the incident with Resident #89 because he is the one who completes the death certificates. The Medical Director said this Resident was tricky because he/she had a lot of comorbidities, but was not considered an expected death because the Resident was not on hospice.

After a facility-wide audit, conducted during survey as part of the facility's removal plan, the facility identified that one more additional staff member's CPR certification had expired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 225506