Royal Wood Mill Center

F-F842

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 30 225505 Department of Health & Human Services Printed: 08/31/2025 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 225505 B. Wing 04/09/2025

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

Royal Wood Mill Center 800 Essex Street Lawrence, MA 01841

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

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

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36797 Residents Affected - Some Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biological's in accordance with State and Federal requirements. Specifically:

1. The facility failed to ensure medication and treatment carts were locked while a nurse was not present and failed to ensure medications were not left unattended on top of the medication cart when a nurse was not present.

2. The facility failed to ensure medications were not left at the bedside for one Resident (#64) out of a total of 20 sampled Residents.

Findings include:

1. Review of the facility policy titled Administering Medications, dated August 2024 indicated that during the administration of medications, the medication cart will be kept closed and locked when out of sight of the nurse. Further review indicated that no medications are to be left on top of the cart and all medications must be inaccessible to residents and other passers by.

Review of the facility policy titled Storage of medications, not dated, indicated that unlocked medication carts are not left unattended.

On 4/6/25, at 7:04 A.M., the surveyor observed the first floor medication carts and a treatment cart open and not in view of the nurse. Nurse #5 then left the area without securing the carts, while the oncoming nurse and 2 residents were in the hallway next to the open carts and had full access to them.

On 4/7/25, at 9:08 A.M. the surveyor observed Nurse #4 walk away from the medication cart with an entire card of Rosuvastatin on top of the cart.

During an interview on 4/07/25, at 9:08 AM Nurse #4 said she should not have left the card of medicine on top of the medication cart

On 4/7/25 at 9:40 A.M., the surveyor observed Nurse #3 seated behind the nurses station. Nurse #3's medication cart was in the hallway, out of view and unlocked and unattended. Nurse #3 then entered the medication room and closed door behind her, while her medication cart continued to be unlocked and unsupervised. Nurse #3 exited the medication room and sat at the nurses station to continue her documentation. Unit Manager #1 arrived on the unit and then secured the medication cart.

During an interview on 4/7/25 at 9:46 A.M., Nurse #3 said she did not lock the medication cart when she should have.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 30 225505 Department of Health & Human Services Printed: 08/31/2025 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 225505 B. Wing 04/09/2025

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

Royal Wood Mill Center 800 Essex Street Lawrence, MA 01841

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

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

F 0761 On 4/7/25, at 10:03 A.M. the surveyor observed Nurse #6 enter a resident's room, on the second floor, to deliver medication. The surveyor observed that Nurse #6 had her back to the medication cart and the Level of Harm - Minimal harm or medication cart was unlocked. The surveyor also observed that there were two residents standing next to the potential for actual harm medication cart, potentially having full access to it.

Residents Affected - Some During an interview on 4/7/25 at 10:11 A.M., Nurse #6 said that she should not have left the medication cart unlocked.

On 4/7/25, at 10:16 A.M., the surveyor observed a treatment cart unlocked on first floor.

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2. Resident #64 was admitted to the facility in August 2024 with diagnoses including malignant neoplasm of unspecified kidney and urinary retention.

Review of the Minimum Data Set assessment dated [DATE REDACTED] indicated Resident #64 is cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam.

During an interview on 4/6/25 at 9:18 A.M., the surveyor observed Resident #64 in bed and a cup of pills on his/her dresser. Resident #64 said the nurse had given him/her the medications and he/she told her that he/she would take the medications and then he/she went back to sleep.

Review of the Medication Administration Record (MAR) for April 2025 on 4/6/25 at 10:17 A.M. indicated nursing had administered the following medications to Resident #64:

HydroCHLOROthiazide Oral Tablet 25 MG (Hydrochlorothiazide) Give 1 tablet by mouth in the morning for HTN

amLODIPine Besylate Oral Tablet 10 MG (Amlodipine Besylate) Give 1 tablet by mouth in the morning for HTN

Colace Oral Capsule 100 MG (Docusate Sodium) Give 1 capsule by mouth two times a day for Constipation

Tamsulosin HCl Oral Capsule 0.4 MG (Tamsulosin HCl) Give 0.4 mg by mouth in the morning related to MALIGNANT NEOPLASM OF UNSPECIFIED KIDNEY

traMADol HCl Oral Tablet 50 MG (Tramadol HCl)

Review of Resident #64's Self Administration of Medications assessment dated [DATE REDACTED] indicated he/she was not able to administer his/her own medications or store medications at bedside.

During an interview on 4/8/25, the Director of Nursing said that medications should not be left at bedside and

the nurse should have administered Resident #64's medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 30 225505 Department of Health & Human Services Printed: 08/31/2025 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 225505 B. Wing 04/09/2025

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

Royal Wood Mill Center 800 Essex Street Lawrence, MA 01841

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

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

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

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36797 potential for actual harm Based on record review and interview, the facility failed to ensure specialized rehab services were provided Residents Affected - Few in a timely fashion for one Resident (#28) out of a total sample of 20 residents.

Findings include:

Review of the facility policy titled Specialized Rehabilitative Services, not dated, indicated that the facility provides specialized rehabilitative services by qualified professional personnel.

Resident #28 was admitted to the facility in January 2025 with diagnoses including stroke with left sided hemiplegia/hemiparesis, contracture of muscle of left hand and dementia.

Review of the Minimum Data Set (MDS) dated [DATE REDACTED] indicated that Resident #28 is totally dependent for all activities of daily living and scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Further review indicated range of motion impairment on one side of upper extremity including wrist and hand.

On 4/06/25, at 7:59 A.M. the surveyor observed Resident #28 lying in bed. The surveyor observed that Resident #28 had a severely contracted hand and fingers. The surveyor also observed that Resident was without a palm guard/splint on the left wrist/hand. The surveyor was not able to locate a palm guard/hand splint in Resident #28's room.

During an interview on 4/06/25, at 7:59 A.M. Resident #28 said that he/she used to have something on his/her hand but has not had one in a long time.

Review of the admission documentation received by the facility from the Resident's prior nursing facility indicated that Resident #28 was receiving occupational therapy to address the contracture's of his/her left hand.

Review of the occupational therapy discharge note from the prior facility, dated 1/20/25, indicated the following:

a. Patient will safely wear least restrictive splinting/orthotic device during daily tasks without skin irritation and complaints of discomfort in order to improve PROM (passive range of motion) for adequate hygiene and inhibit abnormal positions.

b. progress and response to treatment: patient made consistent progress throughout plan of treatment with donning of palm guard s/p (status post) PROM to L (left) digits tolerating 8 hrs (hours).

c. D/C (discharge) recs (recommendations): Recommend continuation of splinting of L hand and PROM to LUE (left upper extremity) at new LTC (long term care) facility.

Review of the progress note, from prior facility, dated 12/30/24, indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 30 225505 Department of Health & Human Services Printed: 08/31/2025 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 225505 B. Wing 04/09/2025

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

Royal Wood Mill Center 800 Essex Street Lawrence, MA 01841

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

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

F 0825 eMar - Medication Administration Note. Note Text: Apply palm guard to left. hand during AM care post hand hygiene as tolerated. every day shift check for placement, reapply as needed, check skin for integrity. unable Level of Harm - Minimal harm or to find. potential for actual harm

On 4/6/25 at 12:32 P.M., the surveyor observed Resident #28 without a palm guard/splint on the left Residents Affected - Few wrist/hand. The surveyor was not able to locate a palm guard/hand splint in Resident #28's room.

On 4/7/25, at 12:14 P.M. the surveyor observed Resident #28 lying in bed without a palm guard/splint on the left wrist/hand. The surveyor was not able to locate a palm guard/hand splint in Resident #28's room.

Review of the physician's orders dated April 2025 failed to indicate an order for a palm guard/hand splint. Further review failed to indicate an order for rehabilitation therapy.

Review of the care plan failed to indicate the use of a palm guard/hand splint.

During an interview on 4/07/25, at 2:33 P.M. the Director of Rehab (DOR) said he was not under the impression from nursing that Resident #28 had been receiving therapy at the previous facility so he did not look for and/or read any therapy notes from the previous facility. The DOR said that it is the responsibility of nursing to inform the rehab department when a resident is admitted who needs therapy, as all admissions are not automatically screened for potential therapy needs. The DOR said that Resident #28 should have been at least screened by therapy upon admission as he/she was receiving occupational therapy at his/her previous nursing home.

During an interview on 4/08/25, at 8:35 A.M., Resident #28 said that he/she was given the palm guard yesterday and that before yesterday he/she did not have one since coming to the building.

During an interview on 4/08/25 at 8:39 A.M., Nurse #7 said that prior to yesterday she had not seen a palm guard/hand splint on Resident #28.

During an interview on 4/08/25, at 8:40 A.M., CNA #5 said that she is Resident #28's regular CNA and she has never seen a palm guard/hand splint for Resident #28 prior to today.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 30 225505 Department of Health & Human Services Printed: 08/31/2025 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 225505 B. Wing 04/09/2025

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

Royal Wood Mill Center 800 Essex Street Lawrence, MA 01841

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

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

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36876

Residents Affected - Some Based on observation, record review and interview, the facility failed to ensure medical records were complete and accurate for 4 residents, (#40, #30, #2 and #268) out of total of 20 sampled Residents. Specifically:

1. For Resident #40, the facility failed to accurately document an order and implementation related to oxygen use.

2. For Resident #30 the facility inaccurately documented that they took blood pressures on the correct arm.

3. For Resident #2, the facility inaccurately documented that they applied both seizure pads in the Resident's bed.

4. For Resident #268, the facility inaccurately documented that the air mattress settings were set correctly.

Findings include:

Review of the Charting and Documentation policy, undated, indicated: Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

1. Resident #40 was admitted to the facility in January 2025 with diagnoses including acute respiratory failure with hypoxia and type II diabetes.

Review of the Minimum Data Set Assessment (MDS) dated [DATE REDACTED] indicated Resident #40 is cognitively intact evidenced by a score of 14 out of 15 in the Brief Interview for Mental Status Exam. The MDS also indicated Resident #40 requires assistance with bathing and dressing.

Additional review of the MDS indicated Resident #40 was on oxygen therapy.

During an interview on 4/6/25 at 7:59 A.M., the surveyor Resident #40 was seated in his/her wheelchair in his/her room not wearing oxygen.

Review Resident #40's physicians orders indicated: O2 @ 1-4L /min via nasal cannula continuous to maintain O2 (oxygen) sats (saturations) greater than 90%, initiated 1/14/25.

Review of Resident #40's care plans indicated:

Focus: The resident requires oxygen therapy r/t (related to) respiratory failure, pulmonary collapse and OSA (obstructive sleep apnea), initiated 1/15/25.

Interventions: Oxygen settings: The resident has 02 @ 1-4L/min as ordered. See MAR (Medication Administration Record).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 30 225505 Department of Health & Human Services Printed: 08/31/2025 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 225505 B. Wing 04/09/2025

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

Royal Wood Mill Center 800 Essex Street Lawrence, MA 01841

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

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

F 0842 On 4/6/25 at 11:46 A.M., the surveyor observed Resident #40 asleep in bed, not wearing oxygen.

Level of Harm - Minimal harm or During an interview on 4/6/25 at 1:08 P.M., Resident #40 was observed in his/her room seated in his/her potential for actual harm wheelchair, not wearing oxygen. Resident #40 said he/she doesn't wear oxygen and hasn't since being in the facility. Residents Affected - Some

During an interview on 4/7/25 at 8:25 A.M., Nurse #3 said that Resident #40 is on oxygen PRN (as needed).

On 4/7/25 at 7:33 A.M., the surveyor observed Resident #40 seated in his/her wheelchair in the lobby area, not wearing 02.

During an interview on 4/7/25 at 9:52 A.M., Unit Manager #1 said that Resident #40 utilizes oxygen PRN. Unit Manager #1 and the surveyor reviewed Resident #40's physicians orders and Unit Manager #1 said that

the order was transcribed in error and it should be PRN.

Review of the January 2025, February 2025, March 2025 and April 2025 MAR indicated nursing staff were signing off on all three shifts that Resident #40 was receiving continuous oxygen daily from admission through 4/7/25; after Unit Manager #1 said that the oxygen order was written incorrectly.

During an interview on 4/8/25 at 8:36 A.M., The Director of Nursing (DON) said that Resident #40's oxygen order should have been PRN and nurses should be paying attention to the orders and documenting medications/treatments that are implemented.

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2. Resident #30 was admitted to the facility in December 2024 with diagnoses including end stage renal disease, dependence on renal dialysis and an arteriovenous fistula.

A review of the most recent Minimum Data Set (MDS) dated [DATE REDACTED] indicated a Brief Interview for Mental Status score of 9 out of a possible 15 indicating moderate cognitive impairment.

A review of Resident #30's April 2025 physician's orders indicated the following:

-No blood pressure on right arm every shift. Start date, 12/9/24.

A review of Resident #30's vitals: blood pressure indicated the following:

-4/4/25, 9:35 P.M., 150/54 mmHg (millimeters of mercury) (Sitting r/arm).

-2/7/25, 5:15 A.M., 134/68 mmHg (millimeters of mercury) (Lying r/arm).

-2/6/25, 2:08 P.M., 150/78 mmHg (millimeters of mercury) (Sitting r/arm).

-1/17/25 10:46 P.M., 110/60 mmHg (millimeters of mercury) (Lying r/arm).

-1/6/25-6:54 A.M., 130/70mmHg (millimeters of mercury) (Lying r/arm).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 30 225505 Department of Health & Human Services Printed: 08/31/2025 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 225505 B. Wing 04/09/2025

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

Royal Wood Mill Center 800 Essex Street Lawrence, MA 01841

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

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

F 0842 -1/5/25-2:45 P.M., 134/67 mmHg (millimeters of mercury) (Lying r/arm).

Level of Harm - Minimal harm or -1/4/25-12:50 A.M., 116/56 mm/Hg (millimeters of mercury) (Lying r/arm). potential for actual harm -1/3/25-1:43 P.M., 110/53 mm/Hg (millimeters of mercury) (Lying r/arm). Residents Affected - Some -1/2/25- 5:50 P.M., 113/57 mm/Hg (millimeters of mercury) (Lying r/arm).

-1/1/25- 8:45 P.M., 100/50 mm/Hg (millimeters of mercury) (Sitting r/arm).

A review of Resident #30's January 2025 Medication Administration Record (MAR) indicated Nurses documented they took the Residents blood pressure on the left arm on 1/17/25 evening shift, 1/6/25 night shift, 1/5/25 day shift, 1/4/25 night shift,1/3/25 day shift, 1/2/25 evening shift, 1/1/25 evening shift.

A review of Resident #30's February 2025 MAR indicated Nurses documented they took the Resident's blood pressure on the left arm on 2/7/25 night shift, 2/6/25 day shift.

A review of Resident #30's April 2025 MAR indicated Nurses documented they took the Resident's blood pressure on the left arm on 4/4/25 day shift.

During an interview and medical record review on 4/7/25 at 12:47 P.M., the Director of Nurses and Unit Manager #1 said the Nurses document accurately in the medical record. They both said Nurses should not document that they took blood pressures on the left arm when they took blood pressures on the right arm.

3. Resident #2 was admitted to the facility in April 2000 with diagnoses including epilepsy and epileptic syndromes with complex and partial seizures.

A review of the most recent Minimum Data Set (MDS) dated [DATE REDACTED] did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely/never understood.

A review of Resident #2's April physician's orders indicated the following:

-Seizure pads to bilateral side rails. Check placement every shift. Order date, 12/21/22.

On 4/7/25 at 7:35 A.M., and 9:40 A.M., the surveyor observed the Resident sleeping in bed with one seizure pad on the left side rail.

On 4/8/25 at 3:35 A.M., the surveyor observed the Resident sleeping in bed with one seizure pad on the left side rail.

A review of Resident # 2's Treatment Administration Record (TAR) indicated that staff had documented on 4/7/25 day shift and 4/8/25 night shift that the Resident had two seizure pads to bilateral side rails while in bed.

During an interview 4/8/25 at 7:40 A.M., the Unit Manager #1 said Nurses should document accurately in the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 225505 Department of Health & Human Services Printed: 08/31/2025 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 225505 B. Wing 04/09/2025

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

Royal Wood Mill Center 800 Essex Street Lawrence, MA 01841

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

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

F 0842 During an interview on 4/8/25 at 7:53 A.M., the Director of Nurses said Nurses should document accurately

in the medical record. The DON said Nurses should not document that the Resident has both seizure pads in Level of Harm - Minimal harm or bed when they only have one. potential for actual harm 4. Resident #268 was admitted to the facility in February 2025 with diagnoses including type 2 diabetes. Residents Affected - Some

A review of the Minimum Data Set, dated dated dated [DATE REDACTED]/5/25 did not indicate a Brief Interview for Mental Status score.

Review of the care plan initiated on 2/24/25 indicated the Resident is not able to make their own health care decisions.

Review of the care plan initiated on 2/26/25 indicated that the Resident has actual impairment to skin integrity as evidenced by a deep tissue injury to right 4th and 5th toe, deep tissue injury to the right lateral heel, deep tissue injury to the left great toe, 4th and 5th toes and a deep tissue injury to the left heel.

Review of Resident #268's April 2025 physician's orders indicated the following:

-Air Mattress-Pressure set per resident's most recent weight, plus or minus 10 pounds.

Document weight. Check placement and function every shift. Order dated, 3/20/25.

Review of Resident #268's most recent weight dated 4/6/25 indicated the Resident weighed 169.8 pounds.

On 4/6/25 at 9:40 A.M., the surveyor observed the Resident in bed. The air mattress was set at 210.

On 4/7/25 at 9:32 A.M., 12:12 P.M., the surveyor observed the Resident in bed. The air mattress was set at 320.

On 4/8/25 at 3:36 A.M., the surveyor observed the Resident in bed. The air mattress was set to 320.

A review of Resident # 268's Treatment Administration Record indicated that Nurses documented on 4/6/25 day shift, 4/7/25 day shift and 4/8/25 night shift that the air mattress was set per the Resident's weight plus or minus 10 pounds.

During an interview on 4/8/25 at 7:51 A.M., the Unit Manager #2 said the Nurses should document accurately in the medical record.

During an interview on 4/8/25 at 7:53 A.M., the Director of Nurses said the Nurses should document accurately in the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 225505 Department of Health & Human Services Printed: 08/31/2025 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 225505 B. Wing 04/09/2025

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

Royal Wood Mill Center 800 Essex Street Lawrence, MA 01841

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36797 potential for actual harm Based on observation, policy review and interview, the facility failed to maintain an infection prevention and Residents Affected - Few control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically the facility failed to:

1. Ensure that nursing performed hand hygiene (HH) and changed a wound dressing in accordance of professional standards to prevent infection.

2. Ensure the nurse did not touch medications while dispensing.

3. Ensure personal protective equipment (PPE) was readily available to staff when needed.

4. For Resident #40, the facility failed to implement contact precautions after he/she developed symptoms and tested positive for Clostridioides difficile (C-Diff; a bacterium that causes an infection of the colon, the longest part of the large intestine).

Findings include:

1. Review of the facility policy titled Dry, Clean Dressings, dated October 2023 indicated that hand hygiene is to be performed before and after glove changes.

Resident #28 was admitted to the facility in January 2025 with diagnoses including stroke with left sided hemiplegia/hemiparesis, dementia and depression.

Review of the Minimum Data Set (MDS) dated [DATE REDACTED] indicated that Resident #28 is totally dependent for all activities of daily living and scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment.

During a dressing change on 4/7/25, at 12:14 P.M., the surveyor observed the following:

Nurse #4 donned gloves and gathered supplies from the treatment cart. Nurse #4 then doffed gloves and donned gloves without performing hand hygiene (HH) potentially contaminating the new gloves. Nurse #4 then poured saline onto gauze and cleaned the pressure ulcer with potentially contaminated gloves. Nurse #4 then doffed her gloves, went to the treatment cart to obtain skin prep and donned new gloves without performing HH potentially contaminating them. Nurse #4 then opened and applied skin prep to the skin surrounding the wound with potentially contaminated gloves on. Nurse #4 then doffed her gloves and donned new gloves without performing HH. Nurse #4 then continued the the wound treatment. Nurse #4 then doffed her gloves and donned new gloves without performing HH two more times during the application of the wound treatment.

During an interview on 4/7/25, at 12:25 P.M., Nurse #4 said that she was supposed to perform HH before and after glove changes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 225505 Department of Health & Human Services Printed: 08/31/2025 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 225505 B. Wing 04/09/2025

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

Royal Wood Mill Center 800 Essex Street Lawrence, MA 01841

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 0880 During an interview on 4/7/25, at 1:48 P.M., the Director of Nursing said that HH is to be performed before donning and after doffing gloves. Level of Harm - Minimal harm or potential for actual harm 2. During medication pass on 4/7/25, at 7:30 A.M. the surveyor observed Nurse #8 to open an acidophilus capsule with her bare hands potentially contaminating the medication. Residents Affected - Few

During an interview on 4/7/25 at 7:45 A.M. Nurse #8 said that she thought because she sanitized her hands

it was ok to touch the pills.

During an interview on 4/8/25, at 7:42 A.M. the Director of Nursing said that it is never okay to touch medication with bare hands.

3. On 4/6/25, at 7:04 A.M. the surveyor observed outside of room [ROOM NUMBER], a precaution sign for enhanced barrier precautions. The surveyor also observed that there was no PPE cart in the area for PPE to be readily available to staff when needed.

During an interview on 4/08/25, at 7:42 A.M. the Director of Nursing said that it is the expectation that a PPE cart is positioned outside of a resident's room who is on enhanced barrier precautions so that PPE is readily available to the staff when needed.

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4. Resident #40 was admitted to the facility in January 2025 with diagnoses including acute respiratory failure with hypoxia and type II diabetes.

Review of the Minimum Data Set Assessment (MDS) dated [DATE REDACTED] indicated Resident #40 is cognitively intact evidenced by a score of 14 out of 15 in the Brief Interview for Mental Status Exam. The MDS also indicated Resident #40 requires assistance with bathing and dressing.

Review of the Clostridium Difficile (C-Diff) policy, undated, indicated: 9. Residents with diarrhea associated with C. difficile (i.e. residents who are colonized and symptomatic) are placed on Contact Precautions. 10. Residents with diarrhea and suspected C. difficile are placed on contact precautions while awaiting laboratory results.

Review of the Nurse Progress Notes indicated:

3/28/2025: Resident reports having diarrhea for days.During 3-11 shift aide reports loose stool x1 will continue to monitor.

3/30/2025: No report of loose stools during shift. Sample picked up from lab. Awaiting further results

4/4/2025: Resident tested positive for C-Diff. [Physician] ordered Vancomycin 125 mg every 6 hrs for 6 weeks.

Review of the physicians orders indicated: All staff must adhere to contact precautions (gown and gloves) every shift for precautions, initiated 4/6/2025; 48 hours after Resident #40 tested positive for C-Diff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 225505 Department of Health & Human Services Printed: 08/31/2025 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 225505 B. Wing 04/09/2025

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

Royal Wood Mill Center 800 Essex Street Lawrence, MA 01841

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 0880 During observations on 4/6/25 at 7:15 A.M., the surveyor observed Resident #40's room. There were no precaution signs or PPE cart indicating he/she was on precautions. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/6/25 at 7:59 A.M. Resident #40 said that he/she had been ill with C-Diff since last week. During the interview, the surveyor observed Unit Manager #1 place a precaution cart outside of Residents Affected - Few Resident #40's room which included personal protective equipment.

During an observation on 4/6/25 at approximately 10:00 A.M., the surveyor observed a sign had been posted outside of Resident #40's room indicating: Contact Precautions; Everyone must clean their hands with alcohol-based hand cleaner or soap and water before entering the room. Providers and staff must also: Put

on gloves before room entry. Discard gloves before room exit. Put on gown before room entry if providing direct care or coming in contact with resident, resident clothing, bedding, etc. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one resident. Use dedicated or disposable equipment. Clean and disinfect re-usable equipment before use on another person.

During an interview on 4/7/25 at 9:52 A.M., Unit Manager #1 said that residents should be placed on contact precautions for C-Diff when symptoms start and when the lab results come back positive. Unit Manager #1 said she did not work on Friday, (4/4/25), when Resident #40's results came back positive. Unit Manager #1 said she put the precaution cart in place, hung the sign and input orders for contact precautions for Resident #40 on 4/6/25; 48 hours after Resident #40 had a confirmed case of C-Diff.

During an interview on 4/8/25 at 7:40 A.M., the Director of Nursing (DON) said that residents should be placed on contact precautions when there is suspicion of C-Diff and a lab pending.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 225505