Twin Oaks Center

F-F773.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 225198 Department of Health & Human Services Printed: 09/18/2025 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 225198 B. Wing 07/11/2024

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

Twin Oaks Center 63 Locust Street Danvers, MA 01923

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 0773 Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41019 Residents Affected - Few Based on record review and interview, the facility failed to promptly notify the physician/ nurse practitioner (NP) of a critically high sodium lab for one Resident (#37), out of a total sample of 18 residents.

Findings include:

Review of the facility policy titled Resident Hydration and Prevention of Dehydration, dated 1/22/2015, indicated the following:

- This facility will endeavor to provide adequate hydration and to prevent and treat dehydration.

- Nursing will assess for signs and symptoms of dehydration as needed and notify the provider to determine needs for hydration.

- If potential inadequate intake and/or signs and symptoms of dehydration are observed, dehydration protocol will be initiated and documented . Provider will be notify [sic] for further interventions.

- Orders may be written for extra fluids to be encouraged between meals and/or with medication passes.

- If nursing assessment indicates significant signs and symptoms of dehydration, labs may be ordered as needed.

Review of the Laboratory Services Agreement indicated the following:

- Notification of Findings: As applicable, Laboratory shall provide immediate telephone notice of results of any critical lab value. Laboratory shall promptly report all other findings as appropriate to the facility.

Resident #37 was admitted with 10/2018 with diagnoses including nontraumatic acute subdural hemorrhage, hypertension, peripheral vascular disease, and cognitive decline.

Review of Resident #37's most recent Minimum Data Set (MDS) assessment, dated 6/19/24, indicated that Resident #37 scored a 9 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of the MDS, dated [DATE REDACTED], indicated Resident #37 required limited assist to one person physical assistance with eating and drinking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 225198 Department of Health & Human Services Printed: 09/18/2025 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 225198 B. Wing 07/11/2024

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

Twin Oaks Center 63 Locust Street Danvers, MA 01923

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 0773 Review of the lab results for Resident #37, dated 12/27/23, indicated Resident #37 had an elevated sodium level of 157, an elevated chloride level of 122, and an elevated blood urea nitrogen (BUN) of 32. [BUN is a Level of Harm - Actual harm test used to assess kidney function and hydration status. Sodium and Chloride are tested to assess hydration status. The normal range for BUN is 10-24 mg/dL (milligrams per deciliter), the normal range for Residents Affected - Few sodium is 133-145 mmol/L (millimoles per liter), and the normal range for chloride is 96-108 mmol/L.]

Review of the clinical record failed to indicate that the physician or NP were notified.

Review of the Nurse Practitioner progress note, dated 12/29/23, does not indicate that the Nurse Practitioner addressed the elevated lab values. There is no indication in the clinical record that any hydration protocol was put in place for Resident #37 to address the elevated labs.

Review of a second lab panel, dated 1/3/24, 5 days after the initial labs drawn, indicated Resident #37 had a critically high sodium level of 160, an elevated chloride level of 122, and an elevated BUN of 30.

During an interview on 7/10/24 at 1:18 P.M., the lab company confirmed that Nurse #1 was notified of the critically high labs via telephone on 1/3/24 at 8:06 P.M. Review of the clinical record failed to indicate that the physician or NP was notified of the critically high sodium level upon notification from the laboratory.

Review of the progress note, dated 1/4/24 at 12:01 P.M., 16 hours after the facility's initial notification of the elevated labs, indicated to send the Resident to the hospital due to dangerously high sodium levels.

Review of the progress note, dated 1/4/24, indicated Note Text: Resident alert and confused, new order from NP to send resident to ER for abnormal result, 2 attends of ambulance picked him up at 5:30 pm.

Review of Resident #37's hospital discharge paperwork indicated Resident #37 was treated in the hospital for hypernatremia (elevated blood sodium), dehydration, and an acute kidney injury.

During an interview on 7/11/24 at 7:54 A.M., the Medical Director said that if a resident comes back with an elevated sodium level, then he would expect that resident to be treated with D5W (intravenous dextrose solution to treat dehydration) and if that could not be performed, then the resident should be sent out to the hospital. The Medical Director said he would expect to be notified immediately of any critically high or high laboratory levels and any sodium above 145 is considered to be high. The Medical Director said that Nurse #1 should have notified the Nurse Practitioner or physician immediately and considered this a delay in treatment for Resident #37.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 225198