Presentation Rehab And Skilled Care Center

F-F610 Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or 48671 potential for actual harm Based on record review and interviews, the facility failed to investigate allegations of abuse for two Residents Residents Affected - Few (#16 and #67) out of a total sample of 27 residents. Specifically,

1. For Resident #16, the facility failed to implement their abuse policy and conduct investigations after allegations of abuse were reported on grievance forms dated 6/17/24 and 7/23/24.

2. For Resident #67, the facility failed to implement their abuse policy and conduct an investigation after allegations of abuse were reported on a grievance form dated 2/5/25.

Findings include:

Review of the facility policy titled Abuse Prevention Program dated March 2022, indicated but was not limited to the following:

- It is the policy of this center to assure an environment free of abuse, neglect, mistreatment and misappropriation of resident property.

- The center Administrator and/or Director of Nurses will be the Abuse Prevention Coordinator.

- Upon receiving an allegation of abuse supervisors will take necessary steps to protect all residents and then immediately notify the Director of Nursing who will notify the Administrator. Appropriate agencies are notified per regulation guidelines.

- The center will report and investigate all allegations of resident abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property. It is the policy of this center when an allegation of abuse, including those involving the posting of an unauthorized photograph or recording of a resident on social media, the center must report the alleged violation to the Administrator/Director of Nursing services and initiate an immediate investigation.

- A thorough investigation will be completed under the direction of the Director of Nursing services and Administrator. Other personnel (Social Worker, etc.) will be included in the investigation as necessary and appropriate. The results of the investigation will be documented in writing and reviewed with the Administrator.

1. Resident #16 was admitted to the facility in June 2024 with diagnoses including unspecified dementia, dysphagia, adjustment disorder with mixed anxiety and depressed mood, weakness and difficulty walking.

Review of the most recent Minimum Data Set (MDS) assessment, dated 3/12/25, indicated that Resident #16 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15.

The MDS further indicated Resident #16 was dependent on staff for functional tasks.

On 4/24/25 at 7:45 A.M., the surveyor reviewed two grievance forms for Resident #16 and dated 6/17/24 and 7/23/24. The grievance forms indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0610 Grievance #1 dated 6/17/24, indicated: Person reporting grievance was a family member. Way staff came in and talked to patient saying stop pooping he came in the room and changed the patient and then left him/her Level of Harm - Minimal harm or naked for 1 1/2 (hours) with nothing on. Had to call again for the person to come back and put some clothes potential for actual harm back on (him/her). He was very rude and talking down to him/her and made him/her feel very bad.

Residents Affected - Few Recommendations:

Plan: Education provided to staff regarding clear communication with the resident. Resident educated on hygiene care provide. Resident agreed to wait until talking is completed before asking to be changed/cleaned/clothed.

Follow-Up: Yes. Resident will be covered with blanket if he/she is being toileted. CNA (certified nursing assistant) will ask if resident is comforted before hygiene care is performed.

Grievance #1 was signed and dated 6/17/24, by Social Worker as reviewed and resolved.

Grievance #2 indicated dated 7/23/24, indicated: Person reporting the grievance was Resident #16. Sunday 7/21/24 CNA came in the room with 2 other people put the tray down and almost dropping on the floor she said that she was not going back in the room for nothing she said he/she had no manners and then fuck you and then gave him/her the finger on the way out of the door and walked out. I went in the room today to ask

the roommate (Roommate #1). I interviewed (him/her) (he/she) said he/she saw CNA give (Resident #16)

the finger on the way out of the room. That is what he/she told me he/she saw her do with her finger in the air.

Recommendations: Met with resident.

Plan: Staff education to be done by leadership.

Actions: Staff went in and talked with the resident to discuss incident and get more clarification. There was a referral to Pulse more comfortable for (him/her).

Follow-up: Yes. Staff education was completed. Staff met with the resident. It is clear how the care will be delivered. Resident pleased.

Grievance #2 was signed and dated 7/24/24, by Social Worker as reviewed and resolved.

Review of Resident #16 social service progress notes did not indicate any information regarding the reported grievances.

The facility failed to provide any initial investigation into the allegations reported on 6/17/24 and 7/23/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0610 During an interview on 4/25/25 at 12:53 P.M., the Social Worker said the family member had a concern for care that was not being provided and said the resident was upset at how the staff treated him/her. The Social Level of Harm - Minimal harm or Worker said customer service education is provided to all staff when customer service issues are reported potential for actual harm and said he did not conduct any interviews or meet with staff regarding these two issues because he was not told to do so by the Director of Nursing (DON). The Social Worker said both issues should have been Residents Affected - Few investigated and reported to identify the staff involved and to address any other concerns by residents to keep them safe. The Social Worker said he signs the grievances when he is told they are completed by the DON.

The surveyor requested all accidents and incidents reported for Resident #16. The facility reported that Resident #16 did not have any documented incidents. The DON was unable to provide any investigations for any of the two grievances listed.

During an interview on 4/25/25 at 1:51 P.M., the Director of Nurses (DON) said she would expect the incidents to have been investigated and reported and said any allegations of abuse or neglect should be investigated and reported to validate concerns. The DON said she was made aware of the concerns and said the interdisciplinary team should have implemented the investigation process the same day. The DON said she does not have any investigation information regarding these incidents.

During a follow-up interview on 4/28/25 at 8:34 A.M., the DON said she found information related to Resident #16's grievance #2 that was reported on 7/23/24. The document contained information that was different from the original grievance form.

During an interview on 4/28/25 at 8:38 A.M., the Administrator said an investigation into the allegation should have implemented, and said the grievances were reviewed at morning meeting the next day. The Administrator said he expects staff to report and follow-up immediately with any allegations or suspected abuse and said the allegations should have been reported to the state agency.

2. Resident #67 was admitted to the facility in January 2024 with diagnoses including multiple sclerosis, weakness, muscle wasting and atrophy, and anxiety disorder,

Review of the most recent Minimum Data Set (MDS) assessment, dated 2/5/25, indicated that Resident #67 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15.

The MDS further indicated Resident #16 was dependent on staff for functional tasks.

On 4/24/25 at 7:48 A.M., the surveyor reviewed one grievance form for Resident #67 dated 2/5/25. The grievance form indicated the following: Person reporting grievance was Resident #67. (Employee 1) Spoke with resident about what he/she calls an incident that happened Wednesday night. See statement.

Review of the statement dated 2/6/25, indicated: I was told by nurse, that (Resident) wanted to see me so I went up to his/her room and he/she told me, I am very upset because last night a female worker was rough with me and pushed me from side to side in bed. It was around 3:00 P.M., and I called because my sheet was wet. I don't think it was fully dry from when they washed it but this woman who was wearing a red dress and very tall and she was upset and pushed me from side to side. She then called in another girl from the other side of hallway but that girl didn't seem interested in helping out and left.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0610 (Writer) I then said, I am sorry that had happened to you and I will let the SW (social worker) know but I have never seen you in bed at 3:00 P.M., so do you maybe think it was later at night? He/she said, Oh you are Level of Harm - Minimal harm or right, I don't nap so it must have been right when I went to bed around 8ish. I then went down to let (social potential for actual harm worker) know the situation.

Residents Affected - Few Plan: 2/6/25, Spoke with resident who states he/she feels safe here. Resident stated an incident happened

the previous evening. He/she stated the girls came in and when giving me a new sheet I told them it was damp and must not have been fully dried in the dryer. When the girl moved me she shoved me. This writer asked (Resident) was the movement rough or fast. (Resident) answered it was fast. I got jostled when asked if he/she was physically hurt (Resident) stated Oh no dear. When asked if (Resident) felt safe here he/she stated Oh yes.

- 2/7/25, Check in with (Resident) again this morning he/she stated All is good! This writer asked how was last night and (Resident) stated Great.

- Action: Gentle handling education with staff on unit.

- Follow-Up: Staff education was done with repeat of gentle handling.

The Grievance form was signed and dated 2/6/25, by Social Worker as reviewed and resolved.

The facility failed to provide any initial investigation into the allegation reported on 2/6/25.

During an interview on 4/25/25 at 1:49 P.M., the Director of Nurses (DON) said she would expect the incidents to been investigated and reported and said any allegations of abuse or neglect should be investigated and reported to validate concerns. The DON said they should have reviewed the grievances and implemented their investigation process the same day to identify staff involved. The DON said she does not have any investigation information regarding the incident.

During an interview on 4/28/25 at 8:37 A.M., the Administrator said an investigation into the allegation should have been implemented and said he expects staff to follow-up immediately with abuse allegations, report and investigate all allegations of suspected abuse and neglect.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0637 Assess the resident when there is a significant change in condition

Level of Harm - Minimal harm or 52138 potential for actual harm Based on observations, record reviews and interviews, the facility failed to accurately code the Minimum Residents Affected - Few Data Set (MDS) assessment for one Resident (#78) out of a total sample of 27 residents. Specifically, the facility failed to ensure that the MDS assessment for Resident #78 coded for a significant change when the Resident signed onto hospice.

Findings include:

Resident #78 was admitted to the facility in June 2024 with diagnoses including malignant neoplasm of colon and failure to thrive.

Review of Resident #78's most recent Brief Interview for Mental Status (BIMS) score dated 3/19/25, indicated the Resident scored 9 out of 15 indicating moderate cognitive impairment.

Review of the most recent Minimum Data Set (MDS) assessment, dated 9/18/24, indicated Resident #78 was receiving hospice care but failed to indicate Resident #78 had a significant change completed upon being signed onto hospice.

Review of Resident #78's current physician orders indicated the following:

- Hospice services initiated 7/12/24.

During an interview on 4/28/25 8:49 A.M., the MDS Nurse said the MDS should have reflected a significant change when the Resident signed onto hospice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46339

Residents Affected - Few Based on observation, record review and interviews, the facility failed to implement the care plan of one Resident (#74), out of a total sample of 27 residents. Specifically, the facility failed to ensure alarms and floor mats were in place as per the care plan.

Findings include:

Review of facility policy titled 'Care Plans, Comprehensive Person-Centered' dated 6/6/22, indicated, but was not limited to, the following:

- A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet

the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Resident #74 was admitted to the facility in April 2025 with diagnoses including repeated falls, mild cognitive impairment and cognitive communication deficit.

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated the Resident scored a 3 out of

a total possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating severely impaired cognition.

Review of the medical records indicated the following:

-A physician order dated 4/10/25: Bed and chair alarm in place related to patient's impulsiveness every shift for impulsiveness.

Review of the care plan date initiated 4/8/25 indicated the following:

-Focus: I (Resident) am at risk for falls related to confusion, gait/balance problems, impulsiveness.

-Interventions: -Bed and alarms are in place

-I (Resident) have floor mats to both sides of my bed.

Review of the fall assessment dated [DATE REDACTED] indicated the Resident scored 11 indicating moderate risk.

On 4/23/25 at 8:29 A.M., the surveyor observed the Resident in his/her bed with one floor mat on the left side of the bed, alarm pad underneath the Resident, string not attached to the alarm box. Other noted mat was folded between the wall and bedside table.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0656 On 4/24/25 at 6:55 A.M., the surveyor observed the Resident lying in his/her bed, bed alarm string from under the beddings not attached to alarm box, floor mat on left side of resident bed. Another noted mat was Level of Harm - Minimal harm or folded between the wall and bedside table. potential for actual harm

On 4/25/25 at 6:50 A.M., Resident was observed lying in his/her bed, one floor mat noted on the left side of Residents Affected - Few the bed.

On 4/25/25 at 8:06 A.M., the Resident was observed sitting in his/her room in a regular armchair, the Resident did not have an alarm on.

During an interview on 4/25/25 at 6:58 A.M., Certified Nursing Assistant (CNA) #1 said Resident has only one floor mat. When the surveyor pointed out the folded mat CNA #1 said she did not know the Resident had two floor mats.

During an interview on 4/25/25 at 8:09 A.M., CNA #2 said he transferred the Resident from the bed to the armchair and did not put the alarm on because the Resident was not sitting on his/her wheelchair where the alarm was.

During an interview on 4/25/25 at 8:11 A.M., Nurse #1 said alarms and floor mats should be in place as ordered.

During an interview on 4/25/25 at 8:36 A.M., Unit Manager #3 said alarms and floor mats should always be in place as per the plan of care and physician orders.

During an interview on 4/25/25 at 10:21 A.M., the Director of Nursing said staff should follow the orders and

the plan of care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0658 Ensure services provided by the nursing facility meet professional standards of quality.

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 to ensure it met professional standards Residents Affected - Few of practice for three Residents (#72, #46 and #16) out of a total sample of 27 residents. Specifically:

1. For Resident #72, the facility failed to set his/her air mattress to the correct pressure.

2. For Resident #46, the facility failed to apply Prevalon boots as ordered.

3. For Resident #16, the facility failed to a) set his/her air mattress to the correct pressure setting, b) failed to apply pressure relieving heel boots as ordered, and c) failed to obtain weekly weights as ordered.

Findings:

1. Resident #72 was admitted to the facility in November 2024 and has diagnoses which include heart failure and renal disease.

Review of Resident #72's Minimum Data Set assessment dated [DATE REDACTED] indicated a Brief Interview for Mental Status exam score of 12 out of a possible 15, signifying moderate cognitive impairment, required substantial staff assistance for bed mobility, at-risk for the development of pressure ulcers, a history of pressure ulcers, and used a pressure-reducing device for the bed.

Review of Resident #72's physician order dated 1/29/25 indicated:

- Low air-loss mattress, check function and settings every shift.

Review of Resident #72's care plan dated 3/6/25 indicated he/she had the potential for pressure injury development related to immobility. Interventions did not include the use of a pressure-reducing device for the bed.

Review of Resident #72's weight taken on 4/23/25 at 9:00 A.M. indicated he/she weighed 116.1 pounds.

Review of the air mattress instructions (Patient Safety Systems model: Flotation Air / Air Plus) undated, indicated Select the correct pressure [either in pounds or kilograms] corresponding to the patient's morphology.

On 4/23/25 at 10:25 A.M., the surveyor observed Resident #72 lying in bed, awake. The air mattress pressure was set to 90 pounds. Resident #72 said the mattress was uncomfortable because it sagged in the middle. Resident #72 said his/her weight was approximately 125 pounds. Resident #72 said he/she did not adjust the air mattress pressure setting.

On 4/24/25 at 8:20 A.M., the surveyor observed Resident #72 lying in bed, awake. The air mattress pressure was set to 100 pounds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0658 On 4/24/25 at 10:51 A.M., the surveyor observed a nurse enter the room to administer medications to Resident #72. The nurse did not assess the air mattress pressure or adjust the setting. Level of Harm - Minimal harm or potential for actual harm During an interview with Unit Manager #1 on 4/24/25 at 2:07 P.M., she said she was unaware there was a discrepancy between Resident #72's weight and the air mattress pressure setting. Unit Manager #1 said the Residents Affected - Few setting is based on the physician's order. Unit Manager #1 said that if the order does not specify a weight then maintenance staff match the setting to the Resident's weight. Unit Manager #1 said nursing staff do not adjust the air mattress pressure settings and that this is the responsibility of maintenance staff.

During an interview on 4/25/25 at 7:52 A.M., the Director of Nursing (DON) said the air mattress pressure setting should either match the Resident's actual weight, or the level of comfort requested by the Resident.

The DON said it was the responsibility of nursing staff, not maintenance staff, to set the correct air mattress setting. The DON said it was facility policy to follow manufacturer's guidelines but that generally staff set the air mattress pressure to match resident weight and comfort.

During an interview with the Regional Director of Facility Management on 4/25/25 at 1:35 P.M., he said it was

the responsibility of nursing staff to determine and adjust air mattress pressure. The Regional Director of Facility Management said maintenance staff only become involved with air mattresses when a repair is required.

46339

2. Resident #46 was admitted to the facility in December 2024 with diagnoses including cerebral infarction (stroke), type 2 diabetes mellitus and chronic pain syndrome.

Review of Resident #46's Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated the Resident scored a 13 out of a total possible 15 in the Brief Interview for Mental Status (BIMS) exam indicating intact cognition.

On 4/23/25 at 9:03 A.M., the surveyor observed Resident #46 lying in his/her bed. The Resident did not have Prevalon boots (heel boots that are designed to reduce the risk of bedsore by keeping the heels floated and relieving pressure) on his/her feet.

On 4/24/25 at 6:58 A.M., the surveyor observed Resident #46 lying in his/her bed. The Resident did not have Prevalon boots on his/her feet.

On 4/24/25 at 10:11 A.M., the surveyor observed Resident #46 lying in his/her bed. The Resident had a Prevalon boot on his/her right foot only.

On 4/25/25 at 6:51 A.M., the surveyor observed Resident #46 lying in his/her bed. The Resident did not have Prevalon boots on his/her feet. There was one prevalon boot on the Resident's wheelchair.

Review of the medical record indicated the following:

- A physician order, dated 12/23/24: Prevalon boot to bilateral heels while in bed every day shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0658 - A care plan, date initiated 12/31/24, with focus of I (Resident) have an actual wound to right lateral heel.

Level of Harm - Minimal harm or Intervention, dated 1/6/25: Prevalon boots at all times remove for skin care daily. potential for actual harm

During an interview on 4/25/25 at 6:55 A.M., Certified Nursing Assistant (CNA) #1 said sometimes she sees Residents Affected - Few the Resident with the boot on but not all the time.

During an interview on 4/25/25 at 8:14 A.M., Nurse #1 said the Resident kicks the boots off when he/she is in bed. When asked if the Resident has declined to have the boots on she said no. She further said there should be bilateral boots available for the Resident as per the order.

During an interview on 4/25/25 at 8:20 A.M., the Resident said he/she would like the Prevalon boots on while

in bed and they don't bother him/her while they are on.

During an interview on 4/25/25 at 8:37 A.M., Unit Manager #3 said the orders for the Prevalon boots should be followed as ordered.

During an interview on 4/25/25 at 10:22 A.M., the Director of Nursing said the Prevalon boots order should be followed as per the physician order.

48671

3a. Resident #16 was admitted to the facility in June 2024 with diagnoses including unspecified dementia, dysphagia, adjustment disorder with mixed anxiety and depressed mood, weakness and difficulty walking.

Review of the most recent Minimum Data Set (MDS) assessment, dated 3/12/25, indicated that Resident #16 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15.

The MDS further indicated Resident #16 was dependent on staff for functional tasks and was at risk of developing pressure ulcers/injuries and required a pressure reducing device for bed and chair.

Review of Resident #16's physician order dated 3/24/25 indicated: Air mattress to prevent pressure injuries. Every shift for Pressure sore prevention.

Review of Resident #16's care plan dated 6/7/24 indicated he/she had an ADL Self Care Performance Deficit r/t (related to) dementia, impaired mobility, and weakness. Interventions included: I have an air mattress. Date Initiated: 03/24/2025

Review of Resident #16's medical record indicated the following:

-3/19/25 weight 145.6 pounds.

On 4/25/25 at 11:33 A.M., the surveyor observed Resident #16 lying in bed, awake. The air mattress pressure was set to 130 pounds. Resident #16 said the mattress was uncomfortable. The air mattress pressure was set to 80-130 pounds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0658 On 4/28/25 at 7:53 A.M., the surveyor observed Resident #16 lying in bed, awake. The air mattress pressure was set to 80-130 pounds. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/28/25 at 7:54 A.M., Certified Nursing Assistant (CNA) #3 said Resident #16 needs

an air mattress because he/she is in bed most of the day and has fragile skin. CNA #3 said he is not familiar Residents Affected - Few with the air mattress and said the settings do not change.

During an interview on 4/28/25 at 8:01 A.M., Nurse #1 said Resident #16's air mattress setting is set by maintenance and goes by the Resident's weight. Nurse #1 said she does not know how to adjust or check

the setting because it stays the same.

During an interview on 4/28/25 at 8:05 A.M., Unit Manager #3 said maintenance staff programs the air mattress settings according to the weight given by the nurse and said there should be a physician order to confirm the correct setting is in place.

During an interview on 4/28/25 at 8:22 A.M., Maintenance Staff #1 said Resident #16 needs a different mattress because it is set too low and would benefit from a different air mattress that provides more support.

During an interview on 4/28/25 at 8:25 A.M., the Director of Nursing (DON) said the air mattress setting should match the Resident's actual weight and it is the responsibility of nursing to check the correct air mattress setting. The DON the facility policy is to follow manufacturer's guidelines and said staff set the air mattress pressure to match residents' weight and comfort.

Review of the air mattress manufacturers user manual, indicated the following:

-Individual home care setting and long-term care.

-Pain management as prescribed by a physician.

-Pump Pressure Range: 20mmHg (millimeters of mercury, unit of pressure) - 55mmHg.

-If pressure is below a user-defined pressure level, the pump will automatically start to inflate the mattress.

The pump will stop when the user-defined pressure level is reached.

3b. On 4/25/25 at 11:33 A.M., the surveyor observed Resident #16 lying in bed, awake. The Resident did not have pressure relieving boots on his/her feet. There were no pressure relieving boots observed in the Resident's room.

On 4/28/25 at 7:53 A.M., the surveyor observed Resident #16 lying in bed, awake. The Resident did not have pressure relieving boots on his/her feet. There were no pressure relieving boots observed in the Resident's room.

Review of the medical record indicated the following physician order dated 3/31/25: Pressure relieving boots to bilateral heels. Check placement of boots every shift, every shift for pressure relieving.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0658 During an interview on 4/28/25 at 7:56 A.M., Certified Nursing Assistant (CNA) #3 said Resident #16 has heel booties but never wears them. CNA #3 was unable to locate the pressure relieving boots in the Level of Harm - Minimal harm or Resident's room. potential for actual harm

During an interview on 4/28/25 at 8:00 A.M., Nurse #1 said the Resident has the booties for his/her heels to Residents Affected - Few keep them elevated but he/she kicks them off sometimes. Nurse #1 said there is a physician order for pressure relieving booties to both heels and said the boots should be available.

During an interview on 4/28/25 at 8:07 A.M., Unit Manager #3 said the orders for the pressure relieving boots should be followed as ordered and made available in the Resident's room.

During an interview on 4/28/25 at 8:22 A.M., the Director of Nursing said the physician order for pressure relieving boots should be followed as indicated according to the physician order.

3c. Review of the nursing progress note, dated 3/21/25, indicated the following:

- Pt (patient) weight loss triggered warning. Pt currently on Ensure (nutritional drink for weight support). NP (Nurse Practitioner) notified. New order: Mirtazapine 7.5 mg PO (by mouth) daily for appetite stimulant.

Review of the physician's orders indicated that Resident #16 had an order for weekly weights dated 3/24/25 and indicated: Weekly weight d/t (due to) weight trend.

Review of the electronic weight record, indicated the last documented weight obtained was on 3/19/25, 145.6 lbs. (pounds).

Review of Resident #16's Medication Administration Record (MAR) for March and April 2025 failed to indicate weights were obtained as ordered. Further review of the medical record indicated a nursing progress note dated 4/24/25, indicating the Resident had one documented weight refusal on 4/24/25.

During an interview on 4/28/25 at 8:03 A.M., Nurse #1 said weights are documented in the electronic medical

record and said weight refusals should be documented on the MAR.

During an interview on 4/28/25 at 8:05 A.M., Unit Manager #1 said weights are listed on the CNA assignment sheet and highlighted to indicate which residents need weekly or monthly weights and the results are documented in the medical record. Unit Manager #1 said weights should be obtained as ordered and documented in the medical record if refused.

Review of the monthly CNA assignment sheets failed to indicate weights were obtained during the months of March and April 2025, and did not contain documentation of refusals of weights.

During an interview on 4/28/25 at 8:29 A.M., the Director of Nurses (DON) said weights should be obtained as ordered and documented in the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or 52138 potential for actual harm Based on record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living Residents Affected - Few (ADLS) for one Resident (#67) out of a total of 27 residents. Specifically, the facility failed to ensure that the Resident was offered and/or provided showers.

Findings include:

Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, last revised March 2018 indicated the following:

- Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLS).

- Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

- 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the residents and in accordance with the plan of care, including appropriate support and assistance with:

a. Hygiene (bathing, dressing, grooming, and oral care).

Resident #67 was admitted to the facility in January 2024 with diagnoses including Multiple Sclerosis, falls and weakness.

Review of Resident #67's Minimum Data Set (MDS) assessment, dated 2/5/25, indicated the Resident scored a 10 out of possible 15 on the Brief Interview for Mental Status exam, indicating he/she was moderately cognitively impaired. The MDS further indicated that the Resident does not exhibit behaviors for rejection of care and the Resident requires substantial to maximal assistance to shower or bathe self.

Review of Resident #67's medical record indicated the following:

- A facility care plan: I (resident) have an ADL Self Care Performance Deficit related to Multiple Sclerosis, dated 1/31/24. With the following interventions: Bathing: I (resident) require assistance of 1 staff with bathing/showering.

Review of the Documentation Survey Report V2 (April 2025) tool failed to indicate documentation of showers given or resident refusal under the shower weekly section.

Review of the medical record failed to indicate a nurse's note to reflect Resident refusals or offers of showers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0677 During an interview on 4/23/25 at 8:35 A.M., Resident #67 said staff never offer him/her a weekly shower and he/she couldn't remember the last time he/she had an actual shower. Resident #67 said he/she would Level of Harm - Minimal harm or like his/her hair washed. potential for actual harm

During an interview on 4/25/25 at 10:35 A.M., Unit Manger #2 said the Certified Nursing Assistant's (CNA's) Residents Affected - Few are educated to let the nurses know when residents refuse a shower so the nurse can reapproach. She also said, the expectation is for the CNA's to document refusals under the shower section and the nurses are expected to document resident refusals with a note reflecting circumstances surrounding refusals.

During an interview on 4/25/25 at 2:33 P.M., the Director of Nursing said she would expect nurses to write a note that corresponds to a resident's refusals because residents forget, and it is important to document refusals so showers can be offered on a different day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46339

Residents Affected - Few Based on observation, record review and interview, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, and in accordance with physician's orders were provided for two Residents (#44, and #109) out of a total sample of 27 residents. Specifically:

1. For Resident #44 the facility failed to, ensure oxygen tubing was changed and dated accurately and ensure the oxygen filter was wiped down.

2. For Resident #109, the facility failed to ensure that a significant change in respiratory status was monitored, assessed, medications ordered by the physician were utilized, and changes in condition were reported timely to the physician for Resident #109; resulting in oxygenation levels falling below parameters, and subsequent death.

Findings include:

Review of facility policy titled 'Oxygen via Nasal Cannula' dated [DATE REDACTED] indicated the following but not limited to:

- Oxygen therapy via nasal cannula is administered as ordered by a nurse practitioner/physician and includes correct flow rate, mode of delivery and humidification.

- Oxygen is set up, delivered and monitored by a licensed nurse or a respiratory therapist.

- Nasal cannula labeled with date of initial set-up.

1. Resident #44 was admitted to the facility in [DATE REDACTED] with diagnoses including acute and chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) and chronic obstructive pulmonary disease (COPD).

Review of Resident #44's Minimum Data Set (MDS) assessment, dated [DATE REDACTED], indicated the Resident scored 11 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she was moderately cognitively impaired. The MDS further indicated that the Resident was on oxygen therapy.

On [DATE REDACTED] at 8:57 A.M., the surveyor observed Resident #44 wearing an oxygen nasal cannula, the oxygen tubing was undated. The oxygen filter was covered with a thick coat of dust.

On [DATE REDACTED] at 7:03 A.M., the surveyor observed Resident #44 wearing an oxygen nasal cannula, the oxygen tubing was dated [DATE REDACTED]. The oxygen filter was covered with a thick coat of dust.

On [DATE REDACTED] at 8:18 A.M., the surveyor and Nurse #1 observed Resident #44 wearing an oxygen nasal cannula, the oxygen tubing was dated [DATE REDACTED]. The oxygen filter was covered with a thick coat of dust.

Review of the current physician orders indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 - Date [DATE REDACTED]: Oxygen tubing and humidifier change every night shift every Wednesday for per protocol and as needed. Level of Harm - Actual harm - Date [DATE REDACTED]: Oxygen at 2 liters per nasal/cannula every shift for COPD exacerbation. Residents Affected - Few

Review of the Resident's oxygen care plan date initiated [DATE REDACTED] indicated the Resident has oxygen therapy related to COPD.

Review of the Treatment Administration Record (TAR) for April indicated the oxygen tubing had been changed on [DATE REDACTED].

During an interview on [DATE REDACTED] at 8:13 A.M., Nurse #1 said the oxygen tubing is changed every 24 hours and for the oxygen filter she said maybe the oxygen company does the cleaning.

During an interview on [DATE REDACTED] at 8:40 A.M., Unit Manager #3 said oxygen tubing is changed weekly on the overnight shift and should be dated. The oxygen filter should be wiped down.

During an interview on [DATE REDACTED] at 9:11 A.M., the Assistant Director of Nursing (ADON) said oxygen tubing is changed weekly on the nightshift and the oxygen filter should be wiped down. She said she does all oxygen equipment rounding every week.

During an interview on [DATE REDACTED] at 10:26 A.M., the Director of Nursing (DON) said nursing should change and date the oxygen tubing weekly. The DON said the oxygen company does the filter changes, but nurses can wipe down the filter. The DON said the oxygen company is at the facility weekly and she was not sure if they had cleaned Resident #44's filter.

48671

2. Resident #109 was admitted to the facility in [DATE REDACTED] with diagnoses that including acute chronic obstructive pulmonary disease (COPD) with acute exacerbation, respiratory failure with hypoxia (low oxygen level), shortness of breath, acute respiratory infection, parkinsonism, unspecified asthma, dysphagia, and personal history of pulmonary embolism.

Review of the most recent Minimum Data Set (MDS) assessment, dated [DATE REDACTED], indicated that Resident #109 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, and required assistance with activities of daily living.

Review of Resident #109's MOLST (Medical Orders for Life Sustaining Treatment) indicated Resident #109 was a DNR (Do Not Resuscitate), DNI (Do not intubate), but wished to be transferred to the hospital in a medical emergency.

Review of Resident #109's progress notes since his/her readmission to the facility on [DATE REDACTED] indicated he/she had been experiencing an increase in shortness of breath, decline of oxygen saturation levels, increased confusion and use of accessory breathing muscles.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 -Resident was readmitted to facility on [DATE REDACTED] with diagnoses of COPD exacerbation, SOB (shortness of breath), pneumonitis/aspiration PNA (pneumonia), acute hypoxic respiratory failure (improved with Level of Harm - Actual harm nebulizers), PMH (past medical history): asthma. He/she reported some SOB on exertion and when lying flat

in bed. He/she states that he/she has some difficulty breathing if the HOB is not elevated while lying down Residents Affected - Few and prefers that we leave the HOB (head of bed) in the elevated position at all times to increase comfort and rest. He/she is currently on 2L (liters) oxygen (O2) via NC (nasal canula) and uses Albuterol Sulfate Inhalation Nebulization Solution every 6 hours for SOB and Ipratropium-Albuterol Inhalation Solution PRN (as needed) every 4 hours for COPD exacerbation. The current interventions in place have increased Residents comfort and decreased SOB while lying in bed. Will continue with current interventions with a goal of decrease episodes of SOB and promote comfort and sleep.

Review of Resident #109's active physician orders indicated the following:

- Ipratropium-Albuterol Inhalation Solution 0XXX,d+[DATE REDACTED].5 (3) MG/3ML (Ipratropium-Albuterol) 1 unit inhale orally three times a day related to chronic obstructive pulmonary disease with (Acute) Exacerbation for 5 Days. Dated [DATE REDACTED].

-Lasix Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day related to heart failure. Dated [DATE REDACTED].

- GuaiFENesin ER Tablet Extended Release 12 Hour 600 MG Give 1 tablet by mouth every 12 hours related to chronic obstructive pulmonary disease with (Acute) Exacerbation for 5 Days. Dated [DATE REDACTED].

- Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for SOB related to unspecified asthma. Dated [DATE REDACTED].

- Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath. Dated [DATE REDACTED].

- Give oxygen 2L via NC if 02 sat is less than 90% as needed for SOB as needed for shortness of breath. Dated [DATE REDACTED].

- Ipratropium-Albuterol Inhalation Solution 0XXX,d+[DATE REDACTED].5 (3) MG/3ML (Ipratropium-Albuterol) 1 application inhale orally every 4 hours as needed for COPD Exac. Dated [DATE REDACTED].

- Skilled Pulmonary Assessment Every Shift every shift related to chronic obstructive pulmonary disease with (Acute) Exacerbation, Asthma. Pulmonary Assessment: lung sounds, SP02, cough and deep breathing exercises. Document finding in progress notes. Lung sound key: C=Clear, R=Rales, Co=Congested, Cr=Crackles, Rh=Rhonchi, Ru=Rubs, W=Wheezes, D=Diminished SOB=SOB while lying flat. Dated [DATE REDACTED].

Review of Resident #109's respiratory care plan, dated [DATE REDACTED], indicated the following interventions:

-I have altered respiratory status/Difficulty Breathing r/t (related to) aspiration pneumonia.

- Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Date Initiated: [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 - Assist me (and my family members PRN) to learn signs of respiratory compromise. Date Initiated: [DATE REDACTED].

Level of Harm - Actual harm - Elevate HOB until respiratory relief is confirmed - encourage me to limit HOB elevation to ,d+[DATE REDACTED] degrees at baseline. Date Initiated: [DATE REDACTED]. Residents Affected - Few - Maintain a clear airway by encouraging me to clear my own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. Date Initiated: [DATE REDACTED].

- Monitor/document/report abnormal breathing patterns to MD (medical doctor): increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. Date Initiated: [DATE REDACTED].

Review of Resident #109's COPD care plan, dated [DATE REDACTED], indicated the following interventions:

-I have COPD exacerbation and asthma. I am S/P (status post) MLOA (medical leave of absence) for respiratory distress, return [DATE REDACTED]. I was treated for Aspiration PNA Date Initiated: [DATE REDACTED].

- Give aerosol (fine mist) or bronchodilators (medication to help breathing) as ordered. Monitor/document any side effects and effectiveness. Date Initiated: [DATE REDACTED].

- Head of bed to be elevated (semi-Fowlers to fowlers) or out of bed upright in a chair during episodes of difficulty breathing (Dyspnea). Date Initiated: [DATE REDACTED].

- Monitor for difficulty breathing (Dyspnea) on exertion. Remind me not to push beyond endurance. Date Initiated: [DATE REDACTED]

- Monitor for s/sx of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB at rest, Cyanosis (discoloration of skin, lips, nailbeds), Somnolence (drowsiness). Date Initiated: [DATE REDACTED].

- Monitor/document/report to MD (medical doctor) PRN any s/sx of respiratory infection: Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing. Date Initiated: [DATE REDACTED].

Review of Resident #109's cardiovascular care plan, dated [DATE REDACTED], indicated the following interventions:

-Administer medication as ordered. Date Initiated: [DATE REDACTED].

- Give oxygen as ordered by the physician. Date Initiated: [DATE REDACTED].

- Monitor/document/report to MD changes in lung sounds on auscultation (i.e. crackles), edema and changes

in weight. Date Initiated: [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 - Monitor/document/report to MD PRN any s/sx (signs and symptoms) of CAD (coronary artery disease): chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, Level of Harm - Actual harm excessive sweating, dependent edema, changes in cap refil (refill), colour [SIC] /warmth of extremities. Date Initiated [DATE REDACTED]. Residents Affected - Few - Vital Signs as ordered and PRN. Notify physician of any abnormal readings (as compared to baseline). Date Initiated: [DATE REDACTED].

Review of the Nurse Practitioner (NP) progress note, dated [DATE REDACTED], indicated the following:

-Continuous on O2 at 2 Liters via NC. O2 Sat (saturation) running between 95%-96%. He/she is alert with baseline confusion. Lung sounds still wheezy. Received Neb (nebulizer) Tx (treatment) Med (medication) compliant and cooperative with Nx (nursing) care. Assessment and Plan: high risk for respiratory distress, will give 02 prn, monitor 02 sats, nebs/inhalers as indicated.

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

- Appears with increased confusion. Health Care Proxy (HCP) visited this afternoon expressed concerns regarding his/her current mental status and respiration. This writer offered to send him out, but family member asked to wait on the result. Chest X-ray (CXR) obtained today at 1:20 P.M.

Review of Resident #109's medical record indicated a chest X-ray was completed on [DATE REDACTED] and indicated

the following: Congestive heart failure. Right lung base atelectasis (collapse of part of the lung) or pneumonia. A persistent spiculated 2.1 cm (centimeter) nodule in the right upper lobe. Malignancy needs to be excluded. Recommend follow-up further evaluation with CT (computer tomography, type of scan).

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

- HCP was updated on CXR, states nodule is not new MD who follow him/her at (another) Medical center knows about it. NP was also notified of results no new orders at this time due to resident was recently treated for pneumonia, wants MD or regular NP to follow up. Supervisor got in touch with NP, he will see resident on [DATE REDACTED].

Review of the medical record failed to indicate Resident #109 was seen by the nurse practitioner on [DATE REDACTED].

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

-At 5:44 P.M., Patient seems to easily De-Sat (low oxygen levels) at 86% while on 2L via NC. Oxygen boosted up at 3 Liters to observe if any respiratory improvement occurred, slightly improved, put it up at 88%. Oxygen saturation slowly increased at a peak of 88% even after Neb treatment administration. Using his/her accessory muscles to breath comfortably, keeping HOB elevated at 45 angles. Patient is alert but very confused, with some fly of ideas noted while conversing with him/her, nonsensical at time. Neb Tx given as scheduled this shift. Will continue to assess. Oxygen saturation seems to be the prime clinical concern serving this patient.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 medical record failed to indicate the physician or nurse practitioner was notified of the change

in respiratory status when Resident #109's oxygen saturation dropped to 86% on 2 Liters of oxygen, was Level of Harm - Actual harm using accessory muscles to breath, was very confused, and increased the oxygen level to 3 Liters when the physician order is for 2 Liters when the oxygen saturation goes under 90%. Residents Affected - Few

Review of the Medication Administration Record (MAR) for [DATE REDACTED] indicated the following:

-[DATE REDACTED], Ipratropim-Albuterol Inhalation Solution was administered as scheduled at 9:00 A.M., oxygen saturation of 88%, at 1:00 P.M., oxygen saturation of 88%.

Review of the daytime Pulmonary assessment dated [DATE REDACTED], indicated: Liter: 2, LS: Wheezing, Min: 15, SOB: Yes, RR: 18, O2 Sats: 88%.

Further review of the MAR on [DATE REDACTED], failed to indicate that Resident #109 was administered any additional medications as indicated, per the physician orders as needed, for the treatment of respiratory distress (or SOB).

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

-At 4:41 P.M., Initially in the morning resident seemed to be anxious and short of breath. Resident was slightly clammy as he/she stared intensely into caregiver's eyes. No signs and symptoms of infection, even though his respiratory rate was elevated and his O2 saturation was 89%.

Review of the medical record failed to indicate the physician or nurse practitioner was notified of the change

in respiratory status when Resident #109's oxygen saturation dropped to 89% on 2 Liters of oxygen, was clammy and had an elevated respiratory rate.

Further review of the MAR on [DATE REDACTED], failed to indicate that Resident #109 was administered any additional medications as indicated, per the physician orders as needed, for the treatment of respiratory distress (or SOB).

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

-At 7:33 A.M., Continues on 2L oxygen therapy via nasal cannula. Patient asking weird questions that make no sense at all.

-At 5:05 P.M., Higher peak of O2 Sat throughout the day shift for this patient was 90% on 3 Liters. When the flow returns to the desired order the O2 Sat running between 86%-88% on 2 Liters. No c/o somatic pain, but appears very fatigued, confused, restless at times and weak to even pick up his/her spoon to eat.

Review of Resident #109's medical record on [DATE REDACTED], failed to indicate staff notified the physician or nurse practitioner of his/her decline in respiratory status when his/her oxygen saturation dropped to 86% to 88% on 2 Liters of oxygen, was documented as very fatigued, confused, restless, weak, and increased the oxygen level to 3 Liters when the physician order is for 2 Liters when the oxygen saturation goes under 90%.

Review of the MAR for [DATE REDACTED] indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 -[DATE REDACTED], Ipratropim-Albuterol Inhalation Solution was administered as scheduled, at 9:00 A.M., oxygen saturation of 90%. Level of Harm - Actual harm Further review of the medical record on [DATE REDACTED], failed to indicate that Resident #109 received any additional Residents Affected - Few nebulizer or inhaler treatments as ordered and only received the one last scheduled dose of Ipratropim-Albuterol Inhalation Solution at 9:00 A.M. as the order was written for 5 days and was discontinued on [DATE REDACTED].

Further review of the MAR on [DATE REDACTED], failed to indicate that Resident #109 was administered any additional medications as indicated, per the physician orders as needed, for the treatment of respiratory distress (or SOB).

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

-At 5:28 P.M., O2 Sat this shift after Neb treatment running between 88%-90%, continuous O2 at 2L via NC. Lung sounds wheezing, SOB observed upon ADL's, skin color is intact. He/she received all his PO (oral) medications including scheduled Neb Tx.

Review of the medical record on [DATE REDACTED], failed to indicate staff notified the physician or nurse practitioner of

the change in respiratory status when Resident #109's oxygen saturation dropped below 90% on 2 Liters of oxygen and was documented as having shortness of breath and wheezing

Further review of the MAR on [DATE REDACTED], failed to indicate that Resident #109 was administered any additional medications as indicated, per the physician orders as needed, for the treatment of respiratory distress (or SOB).

Further review of the medical record failed to indicate that Resident #109 received any nebulizer or inhaler treatments as ordered by the physician and the last documented administration was on [DATE REDACTED] at 9:00 A.M.

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

At approximately 9:08 am, nurse was called to assess Resident. Upon entering in room, Resident was noted lying in bed with breakfast tray in front of him/her. On assessment Resident lying supine, pale and unresponsive with a gasp on tactile stimuli. Oxygen applied. Resident has code status DNR/DNI however may transfer to hospital. Given may transfer status, code blue (emergency response) initiated and 911 was called. Emergency responders in facility, Resident with no pulse, no respiration and no blood pressure. Resident was later pronounced by in house RN.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 During an interview on [DATE REDACTED] at 10:48 A.M., Nurse #3 said she walked into the Residents' room and observed Resident #109 in bed laying on his/her back with oxygen on and was unresponsive, so she rubbed Level of Harm - Actual harm the Resident's chest with her hand and the Resident made a loud gasping sound and she applied more oxygen to the Resident. Nurse #3 said she then ran to call 911 and grabbed the Resident's chart because Residents Affected - Few she did not know the code status. Nurse #3 said once she knew the code status, she called 911 because the Resident's wishes are to be transferred to the hospital. Nurse #3 said staff responded and that she did not return to the Resident's room because EMS arrived and the Resident had no pulse and had passed away. Nurse #3 said Resident #109 required oxygen because his/her saturation drops to the mid to high 80's and sometimes needed 3 liters of oxygen. Nurse #3 said she came in at 9:00 A.M. that day to help out the facility and that she did not obtain vital signs that morning because she just arrived.

During an interview on [DATE REDACTED] at 11:11 A.M., the Nurse Practitioner (NP) said Resident #109 required close monitoring due to his/her fragile respiratory status and said low oxygen levels must be addressed immediately. The NP said nursing staff should have notified him/her immediately of the decline in status, especially because the Resident had recently been sent to the hospital for similar respiratory concerns. The NP said staff should have administered the ordered PRN (as needed) respiratory medications and applied oxygen to prevent oxygen levels from becoming too low. The NP said vital signs should have been documented at a minimum each shift to monitor the Resident's medical status and had the physician or NP been notified, they would determine if the orders should change, or the Resident should be sent to the hospital due to the Residents oxygen levels falling between 86%-90% on 2 liters of oxygen.

Review of Resident #109's medical record failed to indicate an active physician order to obtain vital signs. Further review of the medical record indicated a physician order for Vital Signs every shift, every shift, was discontinued on [DATE REDACTED].

During an interview on [DATE REDACTED] at 11:36 A.M., the Director of Nurses and the Quality Assurance Nurse said staff should have notified the physician or nurse practitioner of the change in condition when it first started and said she would expect staff to follow physician orders for treatment. The DON said the Resident was unable to maintain oxygenation above 90% on 2 Liters of oxygen and required an intervention and said the physician should have been notified and the resident should have been sent to the emergency room for evaluation. The DON said the Resident had an order to be sent to the emergency room and medical record indicated transfer to hospital if needed. The Quality Assurance Nurse said the care plan should have been followed and said it is the expectation of nursing to assess the resident and document a change in condition and notify the physician.

During an interview on [DATE REDACTED] at 1:17 P.M., Resident Representative (RR) #1, who is Resident #109's Healthcare Proxy, said he was concerned about Resident #109's respiratory status because his/her pneumonia diagnosis was not getting better. RR #1 said the recent X-ray indicated a follow up CT scan should be done but it took too long to schedule. RR #1 said staff did not notify him of Resident #109's change in condition and said he didn't expect the Resident to pass away so suddenly because he/she seemed fine prior when visiting. RR #1 said he doesn't know what happened to Resident #109 because it was a sudden change and he was surprised to see Respiratory Failure as the cause of death on the death certificate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46339

Residents Affected - Few Based on observation, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#54) out of a total sample of 27 residents. Specifically, the facility failed to ensure recommendations from behavioral health services were relayed to the physician and implemented for Resident #54.

Findings include:

Review of facility policy titled 'Behavioral Health Services' dated February 2019, indicated the following but not limited to:

- Behavioral health services are provided to residents as needed as part of the interdisciplinary person-centered approach to care.

Resident #54 was admitted to the facility in April 2024 with diagnoses including adjustment disorder with depressed mood.

Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated the Resident scored a 12 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating that the Resident had moderately impaired cognition. The MDS further indicated the Resident was taking psychotropic medication.

Review of Resident #54's Behavioral health notes dated 12/9/24, indicated the following:

- Clinical assessment: Resident is alert and oriented, mood is congruent with affect. He/she smiles, reports that he/she has been doing okay except his/her sleep has not been good. He/she states, I received something for sleep, but it is not helping. Resident is currently on Remeron (an antidepressant) 7.5 (mg) milligram recommending to increase the dose to 15 mg by mouth at hour of sleep. Nursing continues to report dramatic shifts in moods, triggers easily can verbally aggressive to staff. Resident's deny thoughts of self-harm or harm to others.

- Recommendations: Mirtazapine (Remeron) discontinue 7.5 mg. Start Mirtazapine 15 mg by mouth at hour of sleep for sleep and mood.

Review of the medical record failed to indicate that the recommendations were addressed by the facility physician.

Review of active and discontinued orders failed to indicate Mirtazapine 7.5 mg was discontinued and Mirtazapine 15 mg initiated.

Review of Resident #54's Behavioral Health Notes dated 1/13/25 indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0740 Clinical assessment: Resident is alert and oriented, mood congruent with affect, he/she smiles, pleasant reports fair appetite. Continues to endorse poor sleep. He/she sates I get something for sleep, but it is not Level of Harm - Minimal harm or helping. Resident is currently on Remeron 7.5 mg I previously recommended mirtazapine 15 mg, order still potential for actual harm pending. Nursing mood and behavior have both been at baseline. Residents deny thoughts of self-harm or harm to others. Residents Affected - Few - Plan/recommendations: Mirtazapine, discontinue 7.5 mg and start mirtazapine 15 mg by mouth at hour of sleep for insomnia.

Review of the medical record failed to indicate that the recommendations were addressed by the facility physician.

Review of the current physician order dated 5/22/24 indicated the following:

- Mirtazapine oral tablet 7.5 mg give one tablet by mouth at bedtime for insomnia/mood.

During an interview on 4/24/25 at 12:58 P.M., Unit Manager #3 said there were issues with addressing the recommendations but currently the plan is for the Unit Manager to notify the physician of any recommendations. She said the recommendation should have been addressed as the Resident was still experiencing insomnia despite a different drug prescribed.

During an interview on 4/24/25 at 2:48 P.M., the Quality Assurance Nurse said when the recommendations are addressed there should be a progress note written. She said this was an issue that the facility had identified and is working on a quality assurance performance improvement (qapi) plan.

During an interview on 4/25/25 at 10:23 A.M., the Director of Nursing said the recommendations should have been addressed timely.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 45763 potential for actual harm Based on observation and interviews, the facility failed to serve food that was palatable, and at a safe and Residents Affected - Some appetizing temperature, on two of two floors.

Findings include:

During the initial tour of the facility on 4/23/25 the surveyors met with residents; ten residents voiced dissatisfaction with the temperature and/or taste of the food served at the facility.

Review of the resident council minutes, dated 2/13/25, indicated the residents asked for trays to be passed out faster so that food could remain warm when they received their meals.

During the resident group meeting on 4/23/25 at 11:00 A.M. the surveyors met with residents and the following complaints were made by seven residents:

- The food was cold.

- Chicken and fish were too hard/overcooked.

- The alternative meal was overcooked.

- The food was overcooked.

- Eggs were always overcooked.

On 4/25/25 at 8:10 A.M., the surveyor observed that there were two pans of scrambled eggs on the steam table in the main kitchen. Staff removed one of the pans and did not replace it, leaving a large hole for steam/heat to escape from and for the food to lose heat.

On 4/25/25 at 8:31 A.M., the last food truck arrived on the second floor. After all resident trays were served

the surveyor received the test tray at 8:48 A.M.,17 minutes after the truck had arrived, and the following was recorded and observed:

- Scrambled eggs were 110 degrees Fahrenheit and tasted cool, not hot.

- Cream of wheat was 140 degrees Fahrenheit and tasted hot but bland.

- Muffin was 107 degrees Fahrenheit.

- Milk was 50.9 degrees Fahrenheit and tasted cool not cold.

- Juice was 52.5 degrees Fahrenheit and tasted cool not cold.

- Coffee was 141.7 degrees Fahrenheit and tasted hot.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0804 On 4/25/25 at 7:51 A.M., the last food truck arrived on the first floor. After all resident trays were served the surveyor received the test tray at 8:08 A.M., 17 minutes after the truck had arrived, and the following was Level of Harm - Minimal harm or recorded and observed: potential for actual harm - Scrambled eggs were 118.6 degrees Fahrenheit and tasted warm, not hot. Residents Affected - Some - Muffin was 101.5 degrees Fahrenheit and was warm.

- Milk was 51.9 degrees Fahrenheit and tasted cool not cold.

- Juice was 47.5 degrees Fahrenheit and tasted cool not cold.

- Coffee was 150.3 degrees Fahrenheit and tasted hot.

On 4/25/25 at 12:30 P.M., the last food truck arrived on the second floor. After all resident trays were served

the surveyor received the test tray at 12:45 P.M., 15 minutes after the truck had arrived, and the following was recorded and observed:

- Fish was 125.7 degrees Fahrenheit and tasted warm, not hot; the fish was seasoned but had a firm texture.

- [NAME] was 124.8 degrees Fahrenheit and tasted warm, not hot; the rice was bland and had a mushy texture.

- Spinach was 136.4 degrees Fahrenheit and tasted hot.

- Chowder was 145.2 degrees Fahrenheit and tasted hot.

- Milk was 54.5 degrees Fahrenheit and tasted room-temperature, not cold.

- Juice was 54.3 degrees Fahrenheit and tasted room-temperature, not cold.

- Coffee was 155.6 degrees Fahrenheit and tasted hot.

On 4/25/25 at approximately 12:00 P.M., the last food truck arrived on the second floor. After all resident trays were served the surveyor received the test tray at 12:11 P.M., and the following was recorded and observed:

- Fish was 147 degrees Fahrenheit.

- [NAME] was 131 degrees Fahrenheit.

- Spinach was 133 degrees Fahrenheit.

- Chowder was 160 degrees Fahrenheit.

- Milk was 48 degrees Fahrenheit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0804 - Fruit was 53 degrees Fahrenheit and hard.

Level of Harm - Minimal harm or - Coffee was 136 degrees Fahrenheit. potential for actual harm

During an interview on 4/25/25 at 1:54 P.M., the Food Service Director (FSD) said he would expect hot food Residents Affected - Some to be at least 145 degrees Fahrenheit when served to residents and cold food/drinks should be 38 to 40 degrees Fahrenheit when served to residents. The FSD said it should not take staff longer than ten minutes to pass all the trays and that any gaps in the steam table should be covered with pans to retain the heat.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm 52138

Residents Affected - Few Based on record review and interviews, the facility failed to ensure a current hospice plan of care was present in the medical record and coordinated with facility staff for one Resident (#78) out of a total sample of 27 residents.

Resident #78 was admitted to the facility in June 2024 with diagnoses including malignant neoplasm of colon and failure to thrive.

Review of Resident #78's Minimum Data Set (MDS) assessment, dated 9/18/24, indicated the Resident scored a 9 out of possible 15 on the Brief Interview for Mental Status exam, indicating he/she had moderate cognitive impairment. The MDS further indicated that the Resident was receiving hospice services.

Review of Resident #78's medical record indicated the following:

- A physician's order dated 7/12/24, [facility's contracted] Hospice.

- A facility care plan: I have a terminal prognosis related to Colon Cancer, dated 6/13/24.

Review of the medical record failed to indicate the hospice agency's plan of care was available to the staff at

the facility.

During an interview on 4/28/25 at 9:46 A.M., Unit Manager #2 said when a resident is admitted to hospice,

the hospice team would put the hospice plan of care in the resident's hospice binder.

During an interview on 4/28/25 at 9:50 A.M., Social Worker #1 said Resident #78 came from another facility and he/she should have called hospice to retrieve a copy of the hospice plan of care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 49 225486

F-F695

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or 48671 potential for actual harm Based on record review and interview, the facility failed to implement written policies and procedures for the Residents Affected - Few investigation of allegations of abuse, protection of residents during investigations, reporting of allegations and investigative findings, and taking corrective actions to protect other residents from potential abuse for two Residents, (#16 and #67), out of a total sample of 27 residents. Specifically:

1. For Resident #16, the facility failed to initiate their abuse policy after allegations of abuse were reported on grievance forms dated 6/17/24 and 7/23/24.

2. For Resident #67, the facility failed to initiate their abuse policy after allegations of abuse were reported on

a grievance form dated 2/5/25.

Findings include:

Review of the facility policy titled Abuse Prevention Program dated March 2022, indicated but was not limited to the following:

- All employees are responsible for identifying and reporting immediately to their supervisors or any witnessed abuse or allegation of abuse they are told about by residents, families, visitors, or other staff.

- Upon receiving an allegation of abuse supervisors will take necessary steps to protect all residents and then immediately notify the Director of Nursing who will notify the Administrator. Appropriate agencies are notified per regulation guidelines.

- Staff member(s) implicated in a potential neglect or abuse incident will be removed immediately from all resident areas. The employees will be interviewed and may be asked to document the events that allegedly occurred.

- Staff members implicated in any potential neglect or abuse situation will be suspended from work pending

the result of that investigation.

- The center social worker or social worker designee will provide counseling and support to the residents involved to ensure their psychosocial needs are addressed.

Investigation

- The center will report and investigate all allegations of resident abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property. It is the policy of this center when an allegation of abuse, including those involving the posting of an unauthorized photograph or recording of a resident on social media, the center must report the alleged violation to the Administrator/Director of Nursing services and initiate an immediate investigation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0607 1. Resident #16 was admitted to the facility in June 2024 with diagnoses including unspecified dementia, dysphagia, adjustment disorder with mixed anxiety and depressed mood, weakness and difficulty walking. Level of Harm - Minimal harm or potential for actual harm Review of the most recent Minimum Data Set (MDS) assessment, dated 3/12/25, indicated that Resident #16 had mild cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15. The Residents Affected - Few MDS further indicated Resident #16 was dependent on staff for activities of daily living tasks.

On 4/24/25 at 7:45 A.M., the surveyor reviewed two grievance forms for Resident #16 and dated 6/17/24 and 7/23/24. The grievance forms indicated the following:

Grievance #1 dated 6/17/24, indicated: Person reporting grievance was a family member. Way staff came in and talked to patient saying stop pooping he/she came in the room and changed the patient and then left him/her naked for 1 1/2 (hours) with nothing on. Had to call again for the person to come back and put some clothes back on (him/her). He was very rude and talking down to him/her and made him/her feel very bad.

Recommendations:

Plan: Education provided to staff regarding clear communication with the resident. Resident educated on hygiene care provided. Resident agreed to wait until talking is completed before asking to be changed/cleaned/clothed.

Follow-Up: Yes. Resident will be covered with blanket if he/she is being toileted. CNA (certified nursing assistant) will ask if resident is comforted before hygiene care is performed.

Grievance #1 was signed and dated 6/17/24, by the Social Worker as reviewed and resolved.

Grievance #2 dated 7/23/24, indicated: Person reporting the grievance was Resident #16. Sunday 7/21/24 CNA (certified nursing assistant) came in the room with 2 other people put the tray down and almost dropping on the floor she said that she was not going back in the room for nothing she said he/she had no manners and the fuck you and then gave him/her the finger on the way out of the door and walked out. I went in the room today to ask the roommate. I interviewed (him/her) (he/she) said he/she saw CNA give (Resident #16) the finger on the way out of the room. That is what he/she told me he/she saw her do with her finger in the air.

Recommendations: Met with resident.

Plan: Staff education to be done by leadership.

Actions: Staff went in and talked with the resident to discuss incident and get more clarification. There was a referral to Pulse (another facility) more comfortable for (him/her).

Follow-up: Yes. Staff education was completed. Staff met with the resident. It is clear how the care will be delivered. Resident pleased.

Grievance #2 was signed and dated 7/24/24, by the Social Worker as reviewed and resolved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0607 Review of Resident #1's social service progress notes did not indicate any information regarding the reported grievances. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/25/25 at 12:53 P.M., the Social Worker said he is the grievance officer for the facility and Resident #16's family member had a concern for care that was not being provided and said the resident Residents Affected - Few was upset at how the staff treated him/her. The Social Worker said customer service education is provided to all staff when customer service issues are reported and said he did not conduct any interviews or meet with staff regarding these two issues because he was not told to do so by the Director of Nursing. The Social Worker said grievances are discussed during morning meeting with the Director of Nursing and the Administrator. The Social Worker said both issues should have been investigated and reported to identify the staff involved and to address any other concerns by residents to keep them safe. The Social Worker said he signs the grievances when he is told they are completed.

During an interview on 4/25/25 at 1:51 P.M., the Director of Nurses (DON) said she was aware of the reported concerns and said the incidents should have been investigated and reported and said allegations of abuse or neglect should be investigated and reported to validate concerns. The DON said the grievances were reviewed by the interdisciplinary and said she does not have any investigation information regarding

these incidents.

During an interview on 4/28/25 at 8:38 A.M., the Administrator said an investigation into the allegations should have been implemented, and said grievances are reviewed by the Social Worker and Director of Nurses. The Administrator said he expects staff to report grievance concerns and follow-up immediately with any allegations of suspected abuse and report the suspected allegations to the state agency while the facility investigates the report.

2. Resident #67 was admitted to the facility in January 2024 with diagnoses including multiple sclerosis, weakness, muscle wasting and atrophy, and anxiety disorder,

Review of the most recent Minimum Data Set (MDS) assessment, dated 2/5/25, indicated that Resident #67 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15.

The MDS further indicated Resident #16 was dependent on staff for functional tasks.

On 4/24/25 at 7:48 A.M., the surveyor reviewed one grievance form for Resident #67 dated 2/5/25. The grievance form indicated the following: Person reporting grievance was Resident #67. (Employee 1) Spoke with resident about what he/she calls an incident that happened Wednesday night. See statement.

Review of the statement dated 2/6/25, indicated: I was told by nurse, that (Resident) wanted to see me so I went up to his/her room and he/she told me, I am very upset because last night a female worker was rough with me and pushed me from side to side in bed. It was around 3:00 P.M., and I called because my sheet was wet. I don't think it was fully dry from when they washed it but this woman who was wearing a red dress and very tall and she was upset and pushed me from side to side. She then called in another girl from the other side of hallway but that girl didn't seem interested in helping out and left.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0607 (Writer) I then said, I am sorry that had happened to you and I will let the SW (social worker) know but I have never seen you in bed at 3:00 P.M., so do you maybe think it was later at night? He/she said, Oh you are Level of Harm - Minimal harm or right, I don't nap so it must have been right when I went to bed around 8ish. I then went down to let (social potential for actual harm worker) know the situation.

Residents Affected - Few Plan: 2/6/25, Spoke with resident who states he/she feels safe here. Resident stated an incident happened

the previous evening. He/she stated the girls came in and when giving me a new sheet I told them it was damp and must not have been fully dried in the dryer. When the girl moved me she shoved me. This writer asked (Resident) was the movement rough or fast. (Resident) answered it was fast. I got jostled when asked if he/she was physically hurt (Resident) stated Oh no dear. When asked if (Resident) felt safe here he/she stated Oh yes.

- 2/7/25, Check in with (Resident) again this morning he/she stated all is good! This writer asked how was last night and (Resident) stated great.

- Action: Gentle handling education with staff on unit.

- Follow-Up: Staff education was done with repeat of gentle handling.

The Grievance form was signed and dated 2/6/25, by the Social Worker as reviewed and resolved.

Review of Resident #67's social service progress notes did not indicate any information regarding the reported grievance.

The facility failed to provide any initial investigation documentation into the allegations reported on 2/6/25.

Review of the Health Care Facility Report System (HCFRS) on 4/25/25, failed to indicate the facility reported

the allegation to the state agency.

During an interview on 4/25/25 at 1:07 P.M., the Social Worker said he was notified of the concern for rough handling and said the Director of Nurses was out of the facility at the time of the report and the Quality Assurance Nurse was notified. The Social Worker said he did not meet with the Resident. The Social Worker said when the Resident reported rough handling and being pushed by staff, the incident should have been investigated and reported to identify the staff involved and to address any other concerns by residents to keep them safe. The Social Worker said he signed the grievance when he was told it was resolved by the Quality Assurance Nurse.

During an interview on 4/25/25 at 2:00 P.M., the Director of Nurses (DON) said she would expect the concern to be investigated and reported and said staff should have been identified, interviewed and called to obtain staff statements of who was working when the incident was reported. The DON said residents should have been interviewed as part of the process to identify any other issues. The DON said she does not have a file on this and does not know who was involved with the Resident's care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 49 225486 Department of Health & Human Services Printed: 08/28/2025 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 225486 B. Wing 04/28/2025

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

Presentation Rehab and Skilled Care Center 10 Bellamy Street Boston, MA 02135

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 0607 During an interview on 4/25/25 at 2:29 P.M., the Quality Assurance Nurse(QA) said she went to see Resident #67 to address the concerns reported on the grievance form regarding allegations of physical Level of Harm - Minimal harm or abuse by a staff member. QA said she went to see the Resident the same day because I was concerned for potential for actual harm abuse, and I checked in to make sure he/she was okay as I was concerned for his/her safety. QA said she did not interview any staff or residents and could not determine who the staff member was. The QA said she Residents Affected - Few did not call or reach out to any staff members who were on the schedule who may have cared for the Resident. QA said she educated the staff working on 2/6/25 about gentle handling of residents because of

the safety concerns for rough handling and moving residents too fast. QA said she did not report the allegation of abuse to state agency.

During an interview on 4/28/25 at 8:34 A.M., the Administrator said rough handling and shoving needs to be investigated and reported and said grievances must be reviewed and reported to senior management to begin the investigation process for allegations of abuse. The Administrator said he expects staff to report and follow-up immediately with any allegations of suspected abuse and said staff and residents should have been interviewed and statements should have been obtained to ensure no other resident has the same concerns. The Administrator said he was not aware that the incident was not reported to the state agency.

Refer to