Melrose Healthcare

F-F578

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41456

Residents Affected - Few Based on record review and interviews, the facility failed to ensure a Roger's treatment plan (a judge and legal guardian decide when an antipsychotic medication can be administered) was valid and kept up to date for one Resident (#8) out of a total of 23 sampled Residents.

Findings include:

Resident #8 was admitted to the facility in [DATE REDACTED] with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, anxiety.

Review of Resident #8's most recent Minimum Data Set (MDS) dated [DATE REDACTED], indicated the Resident score a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #8 was dependent on staff for self-care tasks.

Review of Resident #8's medical record indicated the Resident has active physician orders for two antipsychotic medications.

Review of Resident #8's medical record indicated a Roger's treatment plan that expired on [DATE REDACTED].

When asked, the facility was unable to provide any documentation that Resident #8's Roger's treatment plan had been renewed and kept up to date by the facility.

During an interview on [DATE REDACTED] at 1:48 P.M., the Social Worker said Resident #8 has a Roger's treatment plan for the use of anti-psychotic medication. The Social Worker said she is responsible for ensuring Resident #8's Roger's order is kept up to date and if the facility wants to make changes, she would be the person responsible for contacting the lawyer to make a court appointment for the changes. The Social Worker said she was unaware Resident #8's Roger's treatment plan was expired and needed to be renewed by the courts.

During an interview on [DATE REDACTED] at approximately 8:00 A.M., the Corporate Nurse said the facility discovered Resident #8's Roger's treatment plan was expired on [DATE REDACTED]. The Corporate Nurse said the social services department should have kept track of this treatment plan and ensured it was kept current and did not expire.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43846

Residents Affected - Some Based on observation and interview, the facility failed to maintain a home-like environment. Specifically,

1. The facility failed to ensure that the second floor was free from odors.

2. For Resident #80, the facility failed to ensure the resident's room did not smell of urine and was free from small black flying insects.

3. For Resident #52, the facility failed to ensure his/her mattress was intact without any missing fabric.

Findings include:

The facility was unable to provide a home-like environment policy.

1. On 4/6/25, the surveyors noted the second floor unit had a strong odor of stale urine and body odor throughout the hallways, and dining area at various times during the day (7:00 A.M. - 3:00 P.M.)

On 4/7/25 and 4/8/25, the surveyors noted the second floor unit had a strong odor of stale urine and body odor throughout the hallways, and dining area at various times during the day (6:45 A.M. - 3:00 P.M.)

During an interview on 4/6/25 at 12:40 P.M., Family member #1 said she comes on different days and different times during the week and the second floor always has a bad smell which is not great for her or the residents.

During the resident group meeting conducted on 4/7/25, 14 out of 16 participating residents complained about the odor of the facility and that there is always a constant bad odor.

During an interview on 4/9/25 at 10:02 A.M., the Activities Director said it has a bad odor on the second floor of the facility at all times.

During an interview on 4/9/25 at 11:13 A.M., the Administrator said he has noticed a smell on the second floor and it is because a resident's foley catheter has leaked into the floor and gotten under the tiles. He said housekeeping does their best to eliminate the odor.

48990

2. Resident #80 was admitted to the facility in February 2024 with diagnoses including hypertension and chronic kidney disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0584 Review of the most recent Minimum Data Set (MDS) assessment, dated 1/30/25, indicated Resident #80 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Level of Harm - Minimal harm or potential for actual harm On 4/6/25 at 7:28 A.M., Resident #80 approached the surveyor in the hallway and said he/she is disgusted with their room because it constantly smells strongly of urine. Resident #80 said it's so bad he/she needs to Residents Affected - Some open the window frequently to help lessen the smell of urine. Resident #80 said he/she spends very little time in the room because of the smell. Resident #80 said he/she has told many staff members about the smell, but nobody does anything about it. Resident #80 further said he/she has expressed concern about cockroaches in the room because staff does not remove old food from the room.

On 4/6/25 at 7:43 A.M, the surveyor entered Resident #80's room which smelled strongly of urine. There was

a bag of soiled briefs visible on the roommate's side of the room. There were multiple open food wrappers and open juice containers scattered throughout the room on surfaces and on the floor. There were condiment packets open and leaking onto the floor. There were greater than ten small black flying insects throughout the room.

On 4/6/25 at 12:12 P.M., the surveyor entered Resident #80's room which smelled strongly of urine. There was a bag with a soiled brief visible on the roommate's side of the room. There were greater than ten small black flying bugs throughout the room. There were multiple open food wrappers and open juice containers scattered throughout the room on surfaces and on the floor. There were condiment packets open and leaking onto the floor. A certified nurse assistant (CNA) delivered a meal tray to Resident #80's roommate and swatted her hand as she walked through the small black flying insects.

On 4/7/25 at 8:45 A.M., the surveyor entered Resident #80's room which smelled strongly of urine. There was a bag with a soiled brief visible on the roommate's side of the room. There were multiple open food wrappers and open juice containers scattered throughout the room on surfaces and on the floor. There were condiment packets open and leaking onto the floor. There were greater than ten small black flying bugs throughout the room.

0n 4/8/25 at 9:14 A.M., the surveyor entered Resident #80's room which smelled strongly of urine. There were multiple open food wrappers and open juice containers scattered throughout the room on surfaces and

on the floor. There were condiment packets open and leaking onto the floor. There were greater than ten small black flying bugs throughout the room.

During an interview on 4/7/25 at 8:48 A.M., CNA #7 said Resident #80 often opens the window, but said she was unsure why. CNA #7 said Resident #80 complains about bugs being in the room, specifically cockroaches, but that she hasn't seen any bugs herself and thinks it's not true.

During an interview on 4/9/25 at 8:18 A.M., the Director of Nursing (DON) and Regional Nurse said staff should attempt to remove wrappers, food, and trash from Resident #80's room. They said yesterday they removed more than 20 juice containers from his/her room and those probably attracted the small black flying insects. They further said if there is an odor of urine present staff should identify and remove the source of scent if possible, and if unable to identify the source, then housekeeping should be notified because it might be in the mattress or somewhere that needs to be cleaned.

41456

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0584 3. Resident #52 was admitted to the facility in October 2022 with diagnoses including dementia legal blindness, and failure to thrive. Level of Harm - Minimal harm or potential for actual harm Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE REDACTED], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have Residents Affected - Some moderate cognitive impairment. The MDS also indicated Resident #52 is dependent on staff for toileting tasks.

On 4/8/25 at 7:18 A.M., the surveyor observed Resident #52's unmade bed. The mattress had a hole in the top layer of material throughout the middle of the mattress with dark brown stains throughout the mattress.

During an interview on 4/8/24 at 2:12 P.M., the Director of Nursing looked at a picture of Resident #52's mattress and said that the mattress should not have any missing layer of fabric and should be replaced. The Director of Nursing said the maintenance department usually inspects all mattresses and if there is damage to a mattress it will be replaced.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish

a grievance policy and make prompt efforts to resolve grievances. Level of Harm - Minimal harm or potential for actual harm 48990

Residents Affected - Few Based on observation, record review and interviews, the facility failed to file a grievance for one Resident (#80), out of 23 total sampled residents. Specifically, the facility failed to ensure staff filed a grievance on behalf of Resident #80, who complained that his/her pants were missing.

Findings include:

Review of the facility policy titled 'Grievances, revised February 2024, indicated:

- If a resident, and/or health care representative, or another interested family member of a resident has a complaint, a staff member will inform the person of the grievance process and assist the resident, or person acting on the resident's behalf, to file a written grievance with the facility using the Grievance form as needed.

- Grievances may be submitted orally or in writing. Note: If a grievance is submitted orally, the facility employee taking the grievance must write it up on the grievance report form.

- The Administrator will document receipt of all grievances on the Grievance Log.

Resident #80 was admitted to the facility in February 2024 with diagnoses including hypertension and chronic kidney disease.

Review of the most recent Minimum Data Set (MDS) assessment, dated 1/30/25, indicated Resident #80 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15.

On 4/6/25 at 7:28 A.M., Resident #80 approached the surveyor in the hallway and said the facility often loses laundry and they do nothing about it. Resident #80 said he/she lost his/her peach pants over two weeks ago and that he/she needs them back because they are important to him/her. Resident #80 said he/she told multiple staff members, and they have done nothing to help him/her get them back. Resident #80 said staff told him/her that he/she is always complaining about something and can you prove those were your pants?

Review of the facilities binder titled 'Grievance Log', dated 2025, on 4/7/25 at 7:20 A.M., failed to indicate any grievances were filed for Resident #80's missing peach pants in the last four months.

During an interview on 4/7/25 at 8:48 A.M., Certified Nurse Assistant (CNA) #7 said Resident #80 often complains of missing laundry but that she does not believe it's actually missing, and he/she probably just misplaced it because the Resident is messy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0585 During an interview on 4/7/25 at 8:54 A.M., the Activities Director said Resident #80 complained about missing pants about two weeks ago and she took him/her down to the laundry department to look for them. Level of Harm - Minimal harm or The Activities Director said she assumed Resident #80 filled out a grievance form, so she did not fill one out potential for actual harm on his/her behalf.

Residents Affected - Few During an interview on 4/7/25 at 9:15 A.M., Resident #80 said he/she went down to the laundry with the Activities Director about two weeks ago to look for the peach pants and they were unable to find them, but that he/she really needs them back for an important appointment.

During an interview on 4/7/25 at 9:32 A.M., the Administrator said every time any item is reported missing by

a resident a grievance form should be filed by either the resident or a staff member. The Administrator said any staff member can fill one out. The Administrator said even if a Resident has behaviors of falsely reporting missing items, or if staff believe they might just have been misplaced, a grievance form always needs to be completed and filed so the missing item can be investigated. The Administrator said a grievance form should have been completed and filed regarding Resident #80's missing peach pants.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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** 43846

Residents Affected - Some Based on observation, record reviews and interviews, the facility failed to ensure resident centered care plans were developed and/or implemented for three Residents (#20, #14, #88) out of a total sample of 23 residents. Specifically,

1. For Resident #20, the facility failed to develop a comprehensive pacemaker care plan.

2. For Resident #14, who was assessed to be at moderate risk for falls the facility failed to implement non-skid strips by his/her bed as per the plan of care.

3. For Resident #88, the facility failed to develop a personalized care plan with resident-specific interventions for suicidal indication history.

4. For Resident #88, the facility failed to develop and implement a personalized care plan for use of a hand orthotic as indicated by Occupational Therapy

Findings include:

1. Review of the facility policy titled, Care of a Resident with a Pacemaker, dated 3/18, indicated the following:

-1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification care upon admission:

a. The name, address, and telephone number of the cardiologist.

b. Type of pacemaker.

c. Type of leads .

d. Manufacturer and model.

e. Serial Number.

f. Date of implant; and

g. Paced rate.

-2. When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including:

a. How the resident's pacemaker was monitored (phone, office, internet);

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 1. Resident #20 was admitted to the facility in October 2024 with diagnoses that included dementia, presence of cardiac pacemaker, heart failure, asthma, and type 2 diabetes. Level of Harm - Minimal harm or potential for actual harm Review of Resident #20's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive Residents Affected - Some impairments.

During an interview on 4/8/25 at 12:20 P.M., Resident #20 said he/she has a pacemaker.

Review of Resident #20's hospital discharge summary, dated 10/3/24, indicated AV block status post pacemaker 3/2022. The discharge summary also indicated the pacemaker checks will be remote on 10/23/24, 1/22/25 and 4/29/25.

Review of Resident #20's cardiac care plan, dated 10/6/24, indicated The Resident's Pacemaker information: Manufacturer: (SPECIFY) Model: (SPECIFY) Serial #: (SPECIFY) Date Implanted:(SPECIFY) Name of Cardiologist: (SPECIFY) Side of Chest: (SPECIFY) Pacemaker checked every year: (SPECIFY) via (SPECIFY). Pacemaker check as ordered.

Review of Resident #20's physician note, dated 3/5/25, indicated AV block status post pacemaker.

Review of Resident #20's physician orders failed to indicate orders relating to his/her pacemaker.

During an interview on 4/8/25 at 12:21 P.M., Nurse #4 said Resident #20 does have a pacemaker but she is not sure how it is monitored or any other details of the pacemaker.

During an interview on 4/8/25 at 2:14 P.M. the Director of Nursing said Resident #20 does have a pacemaker and should have a comprehensive care plan in place with details of the pacemaker.

2. Resident #14 was admitted to the facility in December 2022 with diagnoses that included Alzheimer's disease, dementia, chronic obstructive pulmonary disease, schizophrenia and anxiety.

Review of Resident #14's most recent Minimum Data Set (MDS) assessment, dated 1/23/25, indicated he/she scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she needed supervision/touching assistance for eating. Dependent on toileting hygiene and toileting.

Review of Resident #14's fall care plan, dated 5/9/24, indicated Non-skid strips by the bed.

On 4/6/25 at 8:20 A.M., the surveyor observed Resident #14 in bed, non-skid strips were not in place next to his/her bed.

On 4/7/25 at 7:03 A.M., 8:18 A.M., 11:01 A.M., the surveyor observed Resident #14 in bed, non-skid strips were not in place next to his/her bed.

Review of Resident #14's fall risk evaluation, dated 5/6/24, indicated he/she scored a 12 indicating moderate risk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 During an interview on 4/8/25 at 12:21 P.M., Nurse #4 said Resident #14 is a fall risk and tries to get out of bed at times. Nurse #4 said Resident #20's floor does not have non-skin strips. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/8/25 at 2:14 P.M. the Director of Nursing said Resident #14 is at risk for falls and his/her fall intervention of non-skid strips should be in place. Residents Affected - Some 45984

3. Resident #88 was admitted to the facility May 2024 with diagnoses including atrial fibrillation, coronary atherosclerosis and post-traumatic stress disorder.

Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE REDACTED] indicated that

the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition.

Review of the facility policy titled Suicide Threats, revised and dated November 2017, indicated the following:

- If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly.

Review of Resident #88's Behavioral Health evaluation completed by the Nurse Practitioner, dated 6/6/24, indicated the following:

- Psychiatric History: SI (Suicidal Ideation) Details: I think I tried years ago when I was depressed.

- Clinical Assessment: HX (history) Suicidality.

Review of Resident #88's Behavioral Health evaluation completed by the Nurse Practitioner, dated 8/8/24, indicated the following:

- HPI (History of Present Illness): Expresses passive SI

- Psychiatric History: SI (Suicidal Ideation) Details: I think I tried years ago when I was depressed.

- Clinical Assessment: Passive SI reported to DON (Director of Nursing). HX Suicidality.

Review of Resident #88's current active care plans failed to indicate that a care plan was developed indicating a history of Suicidal Ideations with individualized interventions or plans.

During an interview on 4/7/25 at 1:55 P.M., the Social Worker said when residents are admitted to the facility

we do an in-depth evaluation. The social worker continued to say a part of that evaluation is asking if the Resident has had any history or current suicidal ideations and if they have, an individualized care plan should be developed and implemented. The social worker said she was not aware of Resident #88's history of suicidal ideations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said the facility should have developed a personalized care plan for Resident #88's history of suicidal ideation. Level of Harm - Minimal harm or potential for actual harm 4. Resident #88 was admitted to the facility in May 2024 with diagnoses including atrial fibrillation, coronary atherosclerosis and post-traumatic stress disorder. Residents Affected - Some

Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE REDACTED] indicated that

the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further

review of the MDS indicated that the Resident has upper extremity impairment on one side.

Review of Resident #88's admission MDS dated [DATE REDACTED] indicated that the Resident had upper extremity impairment on one side upon admission to the facility.

During an observation on 4/6/25 at 8:26 A.M., Resident #88 was laying in his/her bed. The surveyor observed his/her right hand in a closed position. When asked if the Resident can flex open his/her right fingers, he/she was unable to open his/her right fingers. Resident #88 said his/her hands have always been like this, the Resident continued to say he/she does not remember seeing therapy recently and does not wear any device for his/her right hand.

Review of Resident #88's current, discontinued, and completed physician's orders since he/she was admitted to the facility, failed to indicate an order for the use of a resting handing splint or for staff to ensure self range of motion exercises were implemented.

Review of Resident #88's Occupational Therapy Evaluation and Plan of Treatment dated 5/23/24, indicated

the following:

- Fine Motor Coordination = Impaired (R hand impaired due to contracture of digits.)

Review of Resident #88's Occupational Therapy Discharge Summary dated from 5/23/24 through 6/3/24, indicated the following:

- Diagnosis: contracture, right hand, stiffness of right hand

- Discharge Recommendations: Complete self-ROM (range of motion) on R hand daily. Use of R handed splint at night.

The surveyor requested a policy on Occupational Therapy services for the facility, the facility said they do not have an Occupational Therapy policy.

Review of Resident #88's Kardex (a form indicating the level of care a resident needs) indicated the following under the Resident Care section: Provide active assistance ROM (range of motion)/strengthening/fine motor movement exercises as needed.

Review of Resident #88's Activities of Daily Living care plan, dated 5/22/24, indicated the following interventions:

- Provide active assistance ROM/strengthening/fine motor movement exercises as needed

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 - Refer resident to OT/PT (occupational therapy/physical therapy) as needed

Level of Harm - Minimal harm or Review of a physician's progress note dated 5/29/24 at 9:30 A.M., indicated the following: potential for actual harm - Neuro patient does have contracture right hand, unable to extend all digits of the right hand. Residents Affected - Some

During an interview on 4/7/25 at 1:10 P.M., the interim Director of Rehab (DOR) said she is in the facility every day and she looks for range of motion changes if she is able. The DOR said the facility's OT is contracted out and is not here every day. The DOR then said the facility's sister buildings are more of a priory for therapy services due to insurance. The DOR then said for residents with range of motion impairments, they would ideally be seen by OT and Resident #88 was only seen last year due to a fall. The DOR said the Resident was admitted to the facility before she started working in the building and he/she should have been seen by OT to assess for range of motion impairments and progress. The DOR said she has only evaluated Resident #88 herself after he/she sustained a fall in the facility last year, not for his/her hand contracture.

During an interview on 4/8/25 at 9:24 A.M., Nurse #8 said Resident #88's right hand has always been contracted and she has never seen him using a splint and she does not remember if he/she has ever been seen by therapy services.

During an interview on 4/8/25 at 10:12 A.M., the Occupational Therapist (OT) said she has not personally evaluated Resident #88. The OT said Resident #88 has a right-hand contracture and he/she has a resting hand splint (a hand splint where the hand will lay flat to prevent the fingers from clenching), but he/she needs

a better splint for his/her right hand. The OT said she did not complete the post-fall evaluation from last year

on Resident 88, but clinically, if the Resident was able to use a resting hand splint, he/she would be able to fully stretch out his/her hand and now he/she cannot which indicates that it is a worsening contracture. The OT said she will be ordering Resident #88 a hand splint with a roll in it since his/her fingers are clenched.

During a follow up interview on 4/8/25 at 10:46 A.M., the OT said she observed Resident #88's hand and she is ordering him/her a new splint with a roll in the fist as it is more appropriate for Resident #88's hand contracture. The OT then said Resident #88 was unable to fully extend his/her right hand upon her evaluation.

During a follow-up interview on 4/8/25 at 11:15 A.M., Resident #88 said he/she has a hand splint in his/her bedside table drawer. Resident #88 proceeded to dig to the bottom of the drawer to pull out a hand splint in a bag which had many belongings on top of it. He/she said it is too uncomfortable, and he/she does not wear it. Resident #88 said he/she does not remember staff members ever coming in to stretch out his/her hand.

During an interview on 4/8/25 at 11:25 A.M., Certified Nursing Assistant #8 said she has worked in the facility for over [AGE] years. CNA #8 said she did not know the Resident has a hand contracture and has never stretched out his/her hands for range of motion. CNA #8 continued to say she has never seen a hand splint for Resident #88.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said Resident #88's interventions from his/her OT Discharge summary should have been followed, he/she should have had his hand stretched Level of Harm - Minimal harm or out daily and he/she should have been using a hand splint. The DON said there should have been potential for actual harm physician's orders in place for these so they can be implemented. The DON said she is not sure how staff can monitor these interventions if there are no physician's orders in for them. Residents Affected - Some

During an interview on 4/9/25 at 10:11 A.M., the Medical Director said the resting hand splint was too uncomfortable for Resident #88. The MD said he would expect staff to encourage him/her to wear it and stretch out his/her hand as able. The MD then said he thinks Resident #88 would have benefited from more therapy services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 43846 potential for actual harm Based on observation, record review and interview, the facility failed to ensure physician orders were Residents Affected - Some implemented for two Residents (#70 and #4) out of a total sample of 23 residents. Specifically,

1. For Residents #70, who is at risk for developing pressure ulcers, the facility failed to ensure his/her air mattress was set according to the physician's order.

2. For Resident #4, the facility failed to follow a physician's order to obtain a Urine Analysis in a timely manner.

Findings include:

Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:

- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.

1. Resident #70 was admitted to the facility in September 2023 with diagnoses that included legal blindness, type 2 diabetes, major depressive disorder, and peripheral vascular disease.

Review of Resident #70's most recent Minimum Data Set (MDS) assessment, dated 3/13/25, indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Further review of the MDS indicated that the Resident is at risk for developing pressure ulcers.

On 4/6/25 at 8:05 A.M. and 12:34 P.M., the surveyor observed Resident #70 in bed on an air mattress. The air mattress was set to 300 lbs (pounds).

On 4/7/25 at 7:05 A.M., 8:20 A.M., and 11:01 A.M., the surveyor observed Resident #70 in bed on an air mattress. The air mattress was set to 300 lbs.

On 4/8/25 at 7:41 A.M. and 10:24 A.M., the surveyor observed Resident #70 in bed on an air mattress. The air mattress was set to 300 lbs.

Review of Resident #70's physician order, dated 2/20/24, indicated Low air loss mattress setting 150.

Review of Resident #70's last weight taken was on 3/2/25 and was 136.5 lbs.

Review of Resident #70's Norton Scale (scale for predicting risk of pressure ulcers), dated 3/7/25, indicated he/she scored a 6 indicating high risk for developing pressure ulcers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 4/8/25 at 11:45 A.M., the surveyor with Nurse #4 observed Resident #70 in bed on an air mattress. The air mattress was set to 300 lbs. Nurse #4 said the air mattress should be set to 150 per the doctor's order. Level of Harm - Minimal harm or Nurse #4 said the Resident is on an air mattress because he/she is at risk for skin breakdown. potential for actual harm

During an interview on 4/8/25 at 2:14 P.M., the Director of Nursing said Resident #70 is at risk for developing Residents Affected - Some pressure ulcers and his/her air mattress should be set per the physician's order.

45984

2. Resident #4 was admitted to the facility in June 2014 with diagnoses including hemiplegia and hemiparesis, dysphagia and epilepsy.

Review of Resident #4's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had

a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment.

Review of Resident #4's physician's orders indicated the following order dated 4/1/25:

- Obtain UA (urine analysis) C&S (culture and sensitivity) r/o (rule out) jaundice, every shift may d/c (discontinue) when obtained.

During an interview on 4/8/25 at 8:46 A.M., Nurse #7 said the Nurse Practitioner came in to see Resident 4 and she said that he/she looked yellow, so she wanted to obtain a urine sample to rule out Jaundice. Nurse #7 then said Resident #4 every time staff take Resident #4 to the bathroom they should attempt to collect a urine sample. Nurse #7 said this should have been followed up on sooner, 100%.

During an interview on 4/8/25 at 10:27 A.M., Nurse Practitioner (NP) #2 review Resident #4's physician's orders with the surveyor, NP #2 said she was not sure why the order was put in to rule out jaundice as she never mentioned that. NP #2 said when she evaluated Resident #4, he/she pointed to his/her abdomen indicating discomfort, so she wanted to collect a urine sample to get more information. Nurse Practitioner #2 said a urine analysis should be obtained within 24 hours.

Review of the Laboratory binder on the first floor B-side nursing station indicated a laboratory requisition form for Resident #4's urine to be obtained. The Form indicated that urine was collected on 4/6/25 but it was not picked up by laboratory for analysis.

During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said when an order for a urine analysis is put in, the urine should be obtained within 24 hours. The DON reviewed the lab requisition form and she said this is the form that is supposed to go with the urine sample when sent out to the lab and she was not sure why the sample was not sent out.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43846 potential for actual harm Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Residents Affected - Some Daily Living (ADLs) for seven Residents (#14, #57, #52, #57, #70, #34, #48 and #4) out of a total sample of 23 residents. Specifically,

1. For Residents #14, #57 and #52, the facility failed to provide incontinent care; and

2. For Residents #57, #70, #34, #48 and #4, the facility failed to provide assistance with meals.

Findings include:

Review of the facility policy titled, Activities of Daily Living (ADLs), dated 11/24, indicated the following:

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

c. Elimination (toileting);

d. Dining (meals and snacks).

1a. Resident #14 was admitted to the facility in December 2022 with diagnoses that included Alzheimer's disease, dementia, chronic obstructive pulmonary disease, schizophrenia and anxiety.

Review of Resident #14's most recent Minimum Data Set (MDS), dated [DATE REDACTED], indicated he/she scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further

review of the MDS indicated he/she needed supervision/touching assistance for eating. The MDS also indicated Resident #14 is dependent on staff for toileting tasks and is always incontinent of urine and frequently incontinent of bowel.

On 4/7/25 at 8:25 A.M., Resident #14 was observed in bed being assisted with his/her breakfast. From 8:25 A.M. to 1:00 P.M., Resident #14 was observed in his/her room and was not observed to have staff offer to toilet him/her or have incontinent care provided.

On 4/8/25 from 7:27 A.M. to 11:35 A.M., Resident #14 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinent care provided.

Review of Resident #14's incontinence care plan, dated 11/1/24, indicated incontinent: check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Apply clean clothes and change clothing PRN after incontinence episodes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 Review of Resident #14's potential skin care plan, dated 11/1/24, indicated Protect skin with incontinent care. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. Level of Harm - Minimal harm or potential for actual harm Review of Resident #14's nursing summary, dated 3/21/25, indicated

Residents Affected - Some - Bathing: dependent.

- Continence: 3. Incontinent of both bowel and bladder.

During an interview on 4/8/25 at 11:29 A.M., Certified Nursing Assistant (CNA) #5 said all residents who are incontinent are expected to have incontinent care provided every two hours.

During an interview on 4/8/25 at 11:29 A.M., Nurse #3 said she expects any residents who are incontinent be checked and/or changed every two hours.

During an interview on 4/8/25 at 11:27 A.M., CNA #5 said Resident #14 is on her assignment to provide care to and that the 11:00 P.M to 7:00 A.M. staff gave Resident #14 his/her morning care. CNA #5 said Resident #14 has been up in the dining room since she started her shift and 7:00 A.M. and has not provided him/her with any incontinence care yet.

On 4/8/25 at 11:39 A.M., the surveyor with CNA #3 observed Resident #14's incontinence brief it was heavily soaked with urine.

During an interview on 4/8/25 at 2:12 A.M., the Director of Nursing said incontinence care should include checking and/or changing residents who are incontinent every two hours.

1b. Resident #57 was admitted to the facility in July 2023 with diagnoses that included Post Traumatic Stress Disorder, dementia, frontotemporal neurocognitive disorder, and depression.

Review of Resident #57's most recent Minimum Data Set (MDS), dated [DATE REDACTED], indicated he/she scored a 00 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further

review of the MDS indicated he/she was dependent for toileting tasks and is frequently incontinent of both bowel and bladder.

On 4/7/25 at 8:30 A.M., Resident #14 was observed in the dining room eating breakfast. From 8:30 A.M. to 1:34 P.M., Resident #14 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinent care provided.

On 4/8/25 from 7:27 A.M. to 11:33 A.M., Resident #14 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinent care provided.

Review of Resident #57's activity of daily living care plan, dated 11/26/24, indicated Toilet use: assist

Review of Resident #57's incontinence care plan, dated 11/13/24, indicated Incontinent: Check every 2-3 hours and as required for incontinence.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 Review of Resident #57's potential skin care plan, dated 4/1/25, indicated Protect skin with incontinent care. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/8/25 at 11:29 A.M., Certified Nursing Assistant (CNA) #5 said all residents who are incontinent are expected to have incontinent care provided every two hours. Residents Affected - Some

During an interview on 4/8/25 at 11:29 A.M., Nurse #3 said she expects any residents who are incontinent be checked and/or changed every two hours.

During an interview on 4/8/25 at 11:33 A.M., CNA #2 said she gave Resident #14 care around 7:00 A.M. today and has not provided incontinent care again today. CNA #2 said Resident #14 is always incontinent and should be changed every two hours but was not.

On 4/8/25 at 11:43 A.M., the surveyor with CNA #2 observed Resident #14's incontinence brief it was heavily soaked with urine. CNA #2 said urine leaked out onto Resident #14's pants and they needed to be changed.

During an interview on 4/8/25 at 2:12 A.M., the Director of Nursing said incontinence care should include checking and/or changing residents who are incontinent every two hours.

1c. Resident #52 was admitted to the facility in October 2022 with diagnoses including dementia legal blindness, and failure to thrive.

Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE REDACTED], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #52 is dependent on staff for toileting tasks.

On 4/7/25 at 8:30 A.M., Resident #52 was observed in the dining room eating breakfast. From 8:30 A.M. to 12:54 P.M., Resident #52 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinent care provided.

On 4/8/25 from 7:30 A.M. to 11:32 A.M., Resident #52 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinence care provided.

Review of Resident #52's incontinence care plan, last revised 4/7/25, indicated the following interventions:

-Incontinent - check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes.

Review of Resident #52's Activity of Daily Living care plan, last revised 4/7/25, indicated the following interventions:

-Toilet use: dependent.

-Incontinent bowel and bladder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 Review of Resident #52's potential for skin impairment care plan, last revised 10/14/24, indicated the following interventions: Level of Harm - Minimal harm or potential for actual harm -Toileting assistance on toileting schedule or routine,

Residents Affected - Some -Protect skin with incontinent care.

Review of the nursing summary dated 3/19/25, indicated Resident #52 is incontinent of both bowel and bladder.

Review of Resident #52's Kardex (a form indicating the level of assistance needed for daily care) indicated

the following:

-Incontinent - check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes.

During an interview on 4/8/25 at 11:29 A.M., Certified Nursing Assistant (CNA) #5 said all residents who are incontinent are expected to have incontinent care provided every two hours.

During an interview on 4/8/25 at 11:29 A.M., Nurse #3 said she expects any residents who are incontinent be checked and/or changed every two hours.

During an interview on 4/8/25 at 11:32 A.M., CNA #3 said he provided Resident #52's morning care before breakfast. CNA #3 said all residents who are incontinent should be checked and/or changed every 2 hours, however, he had not checked or toileted Resident #52 since this morning, 4 hours ago.

During an interview on 4/8/25 at 2:12 A.M., the Director of Nursing said incontinence care should include checking and/or changing residents who are incontinent every two hours.

2a. Resident #57 was admitted to the facility in July 2023 with diagnoses that included Post Traumatic Stress Disorder, dementia, frontotemporal neurocognitive disorder, and depression.

Review of Resident #57's most recent Minimum Data Set (MDS), dated [DATE REDACTED], indicated he/she scored a 00 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further

review of the MDS indicated he/she requires partial/moderate assistance from nursing staff for eating.

On 4/6/25 from 12:36 P.M. to 12:38 P.M., the surveyor observed Resident #57 in the dining room not initiating self feeding. No staff were assisting the Resident.

On 4/7/25 from 12:40 P.M. to 12:49 P.M., the surveyor observed Resident #57 in the dining room not initiating self feeding, playing with his/her food. No staff were assisting the Resident.

On 4/8/25 from 8:39 A.M. to 8:45 A.M., the surveyor observed Resident #57 in the dining room not initiating self feeding. No staff were assisting the Resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 4/6/25 at 12:40 P.M., Family member #1 said the facility is always short staffed especially on the weekends. She said her family member does not receive care and does not get fed his/her Level of Harm - Minimal harm or meal. potential for actual harm

Review of Resident #57's activity of daily living care plan, dated 11/26/24, indicated Eating: supervision/cues Residents Affected - Some to assist.

Review of Resident #57's nutrition assessment, dated 3/26/25, indicated Dining assistance: Total Dependence.

During an interview on 4/8/25 at 9:21 A.M., CNA #2 said Resident #57 needs assistance with his/her meals and staff are suppose to sit and assist them once the Resident receives his/her meal.

During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said staff should be following the Residents' care plan and receive the supervision or assistance as needed.

2b. Resident #70 was admitted to the facility in September 2023 with diagnoses that included legal blindness, type 2 diabetes, major depressive disorder, and peripheral vascular disease.

Review of Resident #70's most recent Minimum Data Set (MDS), dated [DATE REDACTED], indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Further review of the MDS indicated the Resident needs supervision/touching assistance from staff for eating.

On 4/6/25 at 8:35 A.M., the surveyor observed Resident #70 in bed awake with his/her breakfast tray on his/her tray table next to their bed not set up. No staff were present in the room.

On 4/7/25 from 8:19 A.M. to 8:30 A.M., the surveyor observed Resident #70 in bed with his/her breakfast tray

on his/her tray table next to their bed not set up the Resident was observed to struggle to open his/her butter packets. No staff were present in the room.

On 4/7/25 from 12:44 P.M. to 12:47 P.M., the surveyor observed Resident #70 in bed awake with his/her lunch tray on his/her tray table next to their bed not set up. No staff were present in the room.

On 4/8/25 from 8:40 A.M. to 8:48 A.M., the surveyor observed Resident #70 in bed awake with his/her breakfast tray on his/her tray table next to their bed not set up. No staff were present in the room.

On 4/8/25 from 12:55 P.M. to 12:59 P.M., the surveyor observed Resident #70 in bed awake with his/her lunch tray on his/her tray table next to their bed not set up. No staff were present in the room.

Review of Resident #70's activities of daily living, dated 5/21/24, indicated eating: set up, encourage and assist as needed.

Review of Resident #70's active Kardex (a form indicating the level of care needed) indicated eating: set up, encourage and assist as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 Review of Resident #70's nutrition therapy assessment, dated 3/10/25, indicated Dining Assistance: Independent, Supervision. Legal blindness. Level of Harm - Minimal harm or potential for actual harm Review of Resident #70's nursing assessment, dated 3/19/25, indicated the Resident was blind.

Residents Affected - Some Eating: continual supervision (ratio 1:8) Dysfunction: 1. Unable to sequence task/follow simple directions.3. Easily fatigued. 10. Decreased ROM (Range of Motion). 11. Generalized weakness.

Review of Resident #60's ADL flow sheet for 4/6/25 he/she was coded as dependent on staff for eating. On 4/7/25 he/he was coded as supervised for eating. On 4/8/25 for breakfast and lunch coded as supervised.

During an interview on 4/8/25 at 12:05 P.M., CNA #4 said she takes care of Resident #70 regularly but does not supervise him/her or assist them with their meals. CNA #4 said that staff should be following the Resident's Kardex and care plan.

During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said staff should be following the Residents' care plan and receive the supervision or assistance as needed. The DON said the Resident likes their meal left but staff should be setting up his/her meal tray.

41456

2c. Resident #34 was admitted to the facility in February 2024 with diagnoses including hemiplegia.

Review of Resident #34's most recent Minimum Data Set (MDS) dated [DATE REDACTED], indicated the Resident scored 13 out of a possible 15 on the Brief Interview for Mental Status (MDS) which indicated he/she is cognitively intact. The MDS also indicated Resident #34 required partial to moderate assistance for self-feeding tasks.

On 4/6/25 at 8:14 A.M., Resident #34 was observed lying in bed while eating breakfast. There were no staff

in the room to provide assistance if needed and the Resident was not visible from the hallway.

On 4/6/25 at 12:45 P.M., Resident #34 was observed eating lunch at a table at the end of the second-floor unit hallway. There were no staff at that end of the hallway and the Resident was not visible from the nursing station. From 12:45 P.M., to 12:59 P.M., the Resident was observed staring at his/her lunch and not eating.

On 4/7/25 at 8:17 A.M., Resident #34 was observed lying in bed while eating breakfast. There were no staff

in the room to provide assistance if needed and the Resident was not visible from the hallway.

On 4/8/25 at 8:26 A.M., Resident #34 was observed lying in bed while eating breakfast. There were no staff

in the room to provide assistance if needed and the Resident was not visible from the hallway.

Review of Resident #34's Activity of Daily Living care plan, last revised 3/6/35, indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 -Eating: assist to dependent.

Level of Harm - Minimal harm or -Self performance may vary depending on cognition, behavioral symptoms and activity tolerance. potential for actual harm -Explain all procedures and purpose prior to performing task and encourage self-performance. Residents Affected - Some

Review of Resident #34's Kardex (a form indicating the level of care needed for self-care tasks) indicated the following:

-Eating: assist to dependent.

Review of the nursing summary dated 3/21/25, indicated Resident #34 was dependent on staff for self-feeding tasks.

During interviews on 4/8/25 at 9:21 A.M., and 11:20 A.M., Certified Nursing Assistant (CNA)#1 said each resident has their own Kardex that explains what each resident need and staff are to follow. CNA #1 said Resident #34 requires assistance with meals at times and when not needing assistance, the Resident definitely needs cueing from staff to continue with the task.

During an interview on 4/8/25 at 2:12 P.M., the Director of Nursing said she expects care plans to be followed as written to ensure the appropriate level of care is provided to the residents. The Director of Nursing said the nursing assistants are aware of checking the Kardex to ensure they are providing the level of assistance needed. The Director of Nursing said Resident #34 does not always require physical assistance with meals and sometimes just requires supervision. The Director of Nursing said any resident who requires supervision or assistance with meals should either be in the dining room for meals or have a staff member in the room with them while they eat.

2d. Resident #48 was admitted to the facility in September 2024 with diagnoses including Alzheimer's Disease and failure to thrive.

Review of Resident #48's most recent Minimum Data Set, dated dated dated [DATE REDACTED], indicated the Resident scored 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment. The MDS also indicated Resident #48 required partial to moderate assistance from staff for self-feeding tasks.

On 4/6/25 at 8:42 A.M., Resident #48 was observed alone in his/her room, lying in bed with his/her breakfast

on the bedside table in from of him/her. The Resident was not visible from the hallway to staff walking by.

The Resident was not eating his/her food.

On 4/8/25 at 9:04 A.M., Resident #48 was observed sitting in his/her wheelchair next to the bed with his/her breakfast tray in front of him/her. The Resident was not eating his/her breakfast and was not visible to be supervised from the hallway.

Review of Resident #48's Activities of Daily Living care plan, last revised 9/9/24, indicated the following interventions:

-Eating: supv/assist (supervision/assistance)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 -Self-performance varies due to behaviors, cognition.

Level of Harm - Minimal harm or Review of Resident #48's Kardex (a form indicating the level of care needed for self-care tasks) indicated the potential for actual harm following:

Residents Affected - Some -Eating: supv/assist (supervision/assistance)

-Self-performance varies due to behaviors, cognition.

Review of the nursing summary dated 3/19/25, indicated Resident #48 required continual supervision from staff for self-feeding tasks due to inability to sequence/follow simple directions, is easily distracted, has generalized weakness, is unable to initiate or follow-through with tasks and has decreased strength and endurance.

During interviews on 4/8/25 at 9:21 A.M., and 11:20 A.M., Certified Nursing Assistant (CNA)#1 said each resident has their own Kardex that explains what each resident need and staff are to follow. CNA #1 said Resident #48 requires someone to be with him/her at all meals because the Resident does not like to eat. CNA #1 said Resident #48 has been declining and staff have to either feed him/her or provide numerous cues throughout the meal.

During an interview on 4/8/25 at 2:12 P.M., the Director of Nursing said she expects care plans to be followed as written to ensure the appropriate level of care is provided to the residents. The Director of Nursing said the nursing assistants are aware of checking the Kardex to ensure they are providing the level of assistance needed. The Director of Nursing said Resident #48 does not always require physical assistance with meals and sometimes just requires supervision and cueing to continue to eat. The Director of Nursing said any resident who requires supervision or assistance with meals should either be in the dining room for meals or have a staff member in the room with them while they eat.

45984

2e. Resident #4 was admitted to the facility in June 2014 with diagnoses including hemiplegia and hemiparesis, dysphagia and epilepsy.

Review of Resident #4's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had

a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated Resident #4 is dependent on staff for activities of daily living (ADL) and requires partial/moderate assistance with eating.

The surveyor made the following observations:

- On 4/6/25 at 12:05 P.M., Resident #4 was sitting in a dining room and just finished lunch, he/she had various food items all over his/her chest.

- On 4/7/25 at 8:07 A.M., Resident #4 was sitting in a dining room eating breakfast, he/she was observed drinking oatmeal out of a bowl and spilling it on his/her face and chest. Staff did not provide assistance or encourage the Resident to use utensils.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 - On 4/7/25 at 12:18 P.M., Resident #4 was sitting in the dining room eating lunch. The Resident was eating food with his/her hands and was observed to wipe his/her hands on the tablecloth as there was significant Level of Harm - Minimal harm or food residue on his/her hands. Staff were present in the dining room and did not provide assistance. potential for actual harm - On 4/8/25 at 8:19 A.M., Resident #4 was sitting in a dining room eating breakfast and feeding him/herself. Residents Affected - Some There was food residue on his/her chest and lap as well as on the ground below where he/she was sitting. Staff were present in the dining room but did not provide assistance. At 8:44 A.M., while Nurse #7's back was to Resident #4, the Resident attempted to drink from a cup but dropped it and it spilled all over the ground. Resident #4 then proceeded to drink oatmeal from a bowl and spill some on his/her face.

Review of Resident #4's Kardex (a form indicating the level of care a resident needs) failed to indicate what level of feeding assistance he/she needs.

Review of Resident #4's ADL care plan dated and revised 4/26/24 indicated the following intervention: Eating - assist.

During an interview on 4/8/25 at 8:46 A.M., Nurse #7 said Resident #4 only needs supervision with meals and he/she does okay with eating.

During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said staff should be following the Residents' Kardex form to the know what level of feeding assistance they need. The DON said Resident #4 should be getting assistance with meals as needed.

Refer to

F-F725.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 43846 potential for actual harm Based on observation, record review and interview, the facility failed to provide treatment and care in Residents Affected - Few accordance with professional standards of practice for two Residents (#20, and #9), out of a total sample of 23 residents. Specifically,

1. For Resident #20, the facility failed to ensure his/her pacemaker checks were completed.

2. For Resident #9, the failed ensure six bilateral foot wounds were assessed and measured weekly.

Findings include:

1. Review of the facility policy titled, Care of a Resident with a Pacemaker, dated 3/18, indicated the following:

-2. When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including:

a. How the resident's pacemaker was monitored (phone, office, internet);

1. Resident #20 was admitted to the facility in October 2024 with diagnoses that included dementia, presence of cardiac pacemaker, heart failure, asthma, and type 2 diabetes.

Review of Resident #20's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments.

During interview on 4/8/25 at 12:20 P.M., Resident #20 said he/she has a pacemaker.

On 4/6/25 at 12:36 P.M. and 4/8/25 at 12:23 P.M., the surveyor observed Resident #20's room, there was not a pacemaker monitor observed his/her room.

Review of Resident #20's hospital discharge summary, dated 10/3/24, indicated AV block (Atrioventricular block - type of heart block) status post pacemaker 3/2022. The discharge summary also indicated the pacemaker checks will be remote on 10/23/24, 1/22/25 and 4/29/25.

Review of Resident #20's cardiac care plan, dated 10/6/24, indicated checks as ordered.

Review of Resident #20's nursing progress note, dated 10/23/24, indicated Resident has an appointment for remote MD visit (via phone) at 09:30 am [sic] but no call received.

Review of Resident #20's medical record failed to indicate this pacemaker check was ever rescheduled or that the Resident was scheduled for a cardiology appointment outside of the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0684 Review of Resident #20's nursing progress note, dated 2/24/25, indicated HCP (Health Care Proxy) asking about whether the Resident is following with cardiology - pacemaker - reassured resident is being followed Level of Harm - Minimal harm or by cardiology and had a pacemaker check recently. potential for actual harm

Review of Resident #20's physician note, dated 3/5/25, indicated AV block status post pacemaker. Residents Affected - Few

Review of Resident #20's physician orders failed to indicate orders relating to his/her pacemaker.

Review of Resident #20's nursing progress notes from admission to present failed to indicate if his/her pacemaker had been checked.

During an interview on 4/8/25 at 12:21 P.M., Nurse #4 said Resident #20 does have a pacemaker but she is not sure how it is monitored or any other details of the pacemaker.

During an interview on 4/8/25 at 2:14 P.M. the Director of Nursing said there should be nursing progress notes about his/her pacer checks and said she thinks that this Resident goes out to Cardiology for the checks.

48990

2.) Resident #9 was admitted to the facility in November 2024 with diagnoses including diabetes and mild cognitive impairment.

Review of the Minimum Data Set (MDS) assessment, dated 1/23/25, indicated Resident #9 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS indicated Resident #9 had two unstageable pressure ulcers. This MDS also indicated Resident #9 was unable to walk and was dependent on staff for turning in bed, hygiene, and transfers.

Review of Resident #9's entire plan of care related to skin, revised 3/24/25, indicated the Resident had left and right heel arterial ulcers. The entire plan of care failed to indicate the Resident had any other wounds.

On 4/7/25 at 10:36 A.M., the surveyor observed Nurse #5 perform the wound dressing change on Resident #9's bilateral heel pressure ulcers. During this observation, there were six additional wounds on the bilateral feet. The following additional wounds were observed on Resident #9's left foot: two dime sized wounds on

the left lateral foot and one dime sized wound on the left ankle. The following additional wounds were observed on Resident #9's right foot: one dime sized wound on the right lateral foot and two dime sized wounds on the anterior foot. Nurse #5 said all six of these wounds appear to be eschar (necrotic tissue that can develop in wounds). Certified Nurse Assistant (CNA) #7 was present during this observation. Nurse #5 and CNA #7 said these six wounds developed shortly after he/she returned from the hospital (Resident #9 was readmitted to the facility from the hospital on 3/17/25). Nurse #5 said there are no wound treatment orders for these six wounds, and she does not know what type of wounds they are. Nurse #5 said the consultant Wound PA is responsible for assessing these six wounds, in addition to the bilateral heel pressure ulcers, weekly.

Review of Resident #9's admission assessment, dated 3/17/25, indicated the following wounds:

- Right Heel, Type Pressure, length 6 centimeters (cm) by 6.2 cm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0684 - Left Heel, Type: Pressure, length 4.8 cm by 6.5 cm.

Level of Harm - Minimal harm or - Anterior l. (left) foot, Type: Other (specify), length 1.3 cm by 2.1 cm. potential for actual harm - Left late (lateral), Type: Other (specify), length 1.5 cm by 1.5 cm. Residents Affected - Few - Medial Left Archille [sic], Type: Other (specify), length 2 cm by 1.8 cm.

- Right heel proximal scab, Type: Other (specify), length 2 cm by 2.1 cm.

Review of Resident #9's assessments titled 'Weekly Skin Evaluation', dated 3/20/25, 3/27/25, and 4/3/25, failed to indicate any wounds in addition to the left heel and right heel pressure ulcers.

Review of Resident #9's assessments titled 'Non-Pressure Ulcer Evaluation', dated 3/17/25, 3/24/25, and 3/31/25, include assessments and measurements of the left heel and right heel pressure ulcers, but fail to include any mention, assessment, or measurement of the six additional wounds on the bilateral feet. These 'Non-Pressure Ulcer Evaluation' assessments were completed by the Director of Nursing (DON).

Review of Resident #9's consultant Wound PA progress notes, dated 3/24/25 and 3/31/25, failed to include any assessment or measurements of the six additional wounds on the Resident's bilateral feet.

Review of Resident #9's medical record failed to include any wound treatment orders, mention of, assessment, or measurements of any wounds other than relating to the left heel and right heel pressure ulcers from 3/18/25 until the surveyor's wound observation on 4/7/25 (a duration of three weeks).

During an interview on 4/7/25 at 11:42 A.M., The Director of Nursing (DON) said the consultant Wound Physician Assistant (PA) was responsible for assessing and measuring all the wounds on Resident #9's feet.

The DON said the Resident had additional wounds on his/her feet when they were readmitted from the facility on 3/17/25. The DON said they spoke about the additional wounds weekly during risk meeting since his/her re-admission and they should have been assessed and measured weekly. The DON said she expected the consultant Wound PA to have assessed and measured these as well as the bilateral heel wounds weekly.

During an interview on 4/7/25 at 11:47 A.M., the consultant Wound PA said she only assessed any wounds addressed in his/her documentation and the facility was responsible for assessing and measuring any wounds that she was not following. The consultant Wound PA said she did not assess Resident #9's additional six foot wounds and that was the facility's responsibility.

During an interview on 4/7/25 at 2:32 P.M., the Regional Nurse said the facility does not have a policy specific to wound care, but that the expectation is to follow physician's orders for any wounds and the nurses should have wound competencies completed annually to ensure they know how to care for the wounds. The Regional Nurse said all wounds should be assessed and measured weekly.

During a follow up interview on 4/9/25 at 8:07 A.M., the Regional Nurse said those six additional wounds on Resident #9's bilateral feet looked like they were arterial ulcers to her, and they should have been assessed and measured weekly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0684 Refer to

F-F726.

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48990

Residents Affected - Few Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new ulcers from developing for one Resident (#9) out of 23 total sampled residents. Specifically, for Resident #9, the facility failed to implement multiple wound care treatment recommendations as recommended by the consultant Wound Physician Assistant (PA), including not implementing the recommended treatment type and/or at the recommended frequency, resulting in the deterioration of pressure ulcers and development of bilateral heel osteomyelitis (an infection of the bone).

Findings include:

Review of the facility policy titled 'Prevention and management of Pressure Ulcers/Injuries', revised November 2024, indicated:

- If a new pressure ulcer is identified, assess the area and notify the provider for treatment order.

Resident #9 was admitted to the facility in November 2024 with diagnoses including diabetes and mild cognitive impairment.

Review of the Minimum Data Set (MDS) assessment, dated 1/23/25, indicated Resident #9 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS indicated Resident #9 had two unstageable pressure ulcers. This MDS also indicated Resident #9 was unable to walk and was dependent on staff for turning in bed, hygiene, and transferred.

Review of Resident #9's medical record indicated he/she had been transferred and admitted to the hospital

on 3/6/25 for bilateral heel osteomyelitis.

On 4/7/25 at 10:36 A.M., the surveyor observed Nurse #5 perform the wound dressing change on Resident #9's bilateral heels. Resident #9's right heel was observed to be the size of a [NAME] with a red wound bed and the left heel was also approximately the size of a [NAME] with black and tan wound bed. During these wound dressing changes Nurse #5 did not perform any hand hygiene after removing gloves and before applying new ones during six out of eight glove changes. During the other two glove changes, Nurse #5 used alcohol prep pads to sanitize and said this was because she forgot hand sanitizer.

During an interview on 4/7/25 at 11:14 A.M., Nurse #5 said she should have performed hand hygiene during all glove changes but did not.

Review of Resident #9's consultant Wound PA progress note, dated 1/6/25, indicated:

- Left heel unstageable deep tissue injury (DTI) pressure ulcer: not improved.

- Right heel unstageable deep tissue injury pressure ulcer: improved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0686 - Plan: Left heel: Iodosorb (a wound care product, specifically a gel containing iodine, used to clean and promote healing in wet, chronic, or infected wounds) and DPD (dry protective dressing) (4x4 gauze) to the Level of Harm - Actual harm left heel wound changed daily and PRN (as needed).

Residents Affected - Few - Plan: Right heel: Iodosorb and DPD (4x4 gauze) to the right heel wound changed daily and PRN.

Review of Resident #9's physician's order indicated:

- DTI left heel (Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/8/25, scheduled three times a day (once every shift), instead of once daily as recommended by the consultant Wound PA.

- DTI right heel was implemented as recommended.

Review of Resident #9's Treatment Administration Record (TAR), dated 1/8/25 to 1/12/25, indicated the above order for the left heel was documented as implemented three times each day (once every shift), instead of once daily as recommended by the consultant Wound PA).

Review of Resident #9's consultant Wound PA progress note, dated 1/13/25, indicated:

- Left heel unstageable deep tissue injury pressure ulcer: not improved.

- Right heel unstageable necrosis pressure ulcer: not improved.

- Plan: Left heel: Iodosorb and DPD (4x4 gauze) to the left heel wound changed daily and PRN.

- Plan: Right heel: Iodosorb and DPD (4x4 gauze) to the right heel wound changed daily and PRN.

Review of Resident #9's physician's order indicated:

- DTI left heel (Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/8/25, scheduled three times a day (once every shift), instead of once daily as recommended by the consultant Wound PA.

- DTI right heel was implemented as recommended.

Review of Resident #9's Treatment Administration Record (TAR), dated 1/13/25 to 1/19/25, indicated the above order for the left heel was documented as implemented three times each day (once every shift), instead of once daily as recommended by the consultant Wound PA.

Review of Resident #9's consultant Wound PA progress note, dated 1/20/25, indicated:

- Left heel unstageable necrosis pressure ulcer: not improved.

- Left heel unstageable necrosis pressure ulcer size increased since last visit on 1/13/25 from 1.6 cm (centimeters) length x 3.8 cm width x non-measurable depth to 2.0 cm length x 4.2 cm width x non-measurable depth.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0686 - Right heel unstageable necrosis pressure ulcer: improved.

Level of Harm - Actual harm - Plan: Left heel: Iodosorb and DPD (4x4 gauze) to the left heel wound changed daily and PRN.

Residents Affected - Few - Plan: Right heel: Iodosorb and DPD (4x4 gauze) to the right heel wound changed daily and PRN.

Review of Resident #9's physician's order indicated:

- DTI Left heel (Twice Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/22/25, scheduled two times a day (day and evening shift), instead of once daily as recommended by the consultant Wound PA.

Review of Resident #9's Treatment Administration Record (TAR), dated 1/20/25 to 1/22/25, indicated the above order for the left heel was documented as implemented three times a day (once each shift) on 1/20/25 and 1/21/25, instead of once daily; and was documented as implemented twice daily (day and evening shift)

on 1/22/25 (instead of once daily as recommended by the consultant Wound PA).

Review of Resident #9's nursing progress note, dated 1/23/25, indicated:

- R (right) heel warm to touch, malodorous, purulent (containing or producing pus) drainage, erythema.

- New orders received for doxycycline (an antibiotic medication).

- New wound care orders. wound dressing change bid (twice daily), may apply betadine(a topical antiseptic)/iodosorb cover with hydrofera blue (an antibacterial wound dressing).

- Review of this note failed to indicate any changes in condition or changes to physician's orders to left heel wound treatment.

Review of Resident #9's physician's order indicated:

- DTI Left heel (Twice Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/22/25, scheduled two times a day (day and evening shift), instead of once daily as recommended by the consultant Wound PA.

- DTI right heel was implemented as ordered by the physician.

Review of Resident #9's Treatment Administration Record (TAR), dated 1/23/25 to 1/26/25, indicated the above order for the left heel was documented as implemented two times (day and evening shift) each day (instead of once daily as recommended by the consultant Wound PA).

Review of Resident #9's consultant Wound PA progress note, dated 1/27/25, indicated:

- Left heel unstageable necrosis pressure ulcer: not improved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0686 - Left heel unstageable necrosis pressure ulcer size increased since last visit on 1/20/25 from 2.0 cm length x 4.2 cm width x non-measurable depth to 2.5 cm length x 5.0 cm width x non-measurable depth. Level of Harm - Actual harm - Right heel unstageable necrosis pressure ulcer: not improved. Residents Affected - Few - Right heel unstageable necrosis pressure ulcer size increased from 1.4 cm length x 3.0 cm width x non-measurable depth to 2.0 cm length x 5.0 cm width x non-measurable depth.

- Plan: Left heel: Iodosorb, DPD (4x4 gauze), and kling to left heel wound changed daily and PRN.

- Plan: Right heel: Bactroban, Alginate, DPD (4x4 gauze), and kling to the right heel changed daily and PRN.

Review of Resident #9's physician's order indicated:

- DTI left heel (Twice Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/22/25, scheduled twice (day and evening shift) a day, instead of once daily as recommended by the consultant Wound PA.

- DTI right heel (Twice Daily/prn) Cleanse with saline, apply bactroban followed by Alginate, skin prep to surroundings, DPD, initiated 1/29/25, scheduled twice daily (day and evening shift), instead of once daily as recommended by the consultant Wound PA.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.

Review of Resident #9's Treatment Administration Record (TAR), dated 1/27/25 to 2/2/25, indicated the above order for the left heel and right heel was documented as implemented two times each day (day and evening shift), instead of once daily as recommended by the consultant Wound PA.

Review of Resident #9's Medication Administration Record (MAR), dated 1/27/25 to 2/2/25, indicated the following order documented as implemented daily.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for right heel as recommended by the consultant Wound PA.

During an interview on 4/8/25 at 10:56 A.M., Nurse #5 said she had put an additional order in for Iodosorb on 1/8/25 so it would be ordered from the pharmacy. Nurse #5 said that order should have been discontinued when the Wound PA recommended it to be discontinued but was not. Nurse #5 said since it was not, the iodosorb had been applied to heels since 1/8/25, even when it shouldn't have been.

Review of Resident #9's consultant Wound PA progress note, dated 2/3/25, indicated:

- Left heel unstageable necrosis pressure ulcer: improved.

- Right heel unstageable necrosis pressure ulcer: not improved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0686 - Plan: Left heel: Iodosorb, DPD (4x4 gauze), and kling to left heel wound changed daily and PRN.

Level of Harm - Actual harm - Plan: Right heel: Bactroban, Alginate, DPD (4x4 gauze), and kling to the right heel changed daily and PRN.

Residents Affected - Few Review of Resident #9's physician's order indicated:

- DTI right heel (Twice Daily/PRN) Cleanse with saline, apply bactroban followed by alginate, skin prep the surroundings, DPD/kling wrap, once daily (of note, this order also indicates twice daily), initiated 2/5/25.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.

Review of Resident #9's Medication Administration Record (MAR), dated 2/3/25 to 2/9/25, indicated the following order documented as implemented daily.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.

Review of Resident #9's consultant Wound PA progress note, dated 2/10/25, indicated:

- Recommend X-ray of the right heel to rule out osteomyelitis of the right heel.

- Left heel arterial wound: improved.

- Right heel arterial wound: not improved.

- New right proximal heel arterial wound.

- Plan: Left heel: Iodosorb, DPD (4x4 gauze), and kling to left heel wound changed daily and PRN.

- Plan: Right heel: Iodosorb, DPD (4x4 gauze), and kling to right heel wound changed daily and PRN.

- Plan: Right proximal heel: Iodosorb, DPD (4x4 gauze), and kling to right proximal heel wound changed daily and PRN.

During an interview on 4/7/25 at 11:47 A.M., the consultant Wound PA was unable to say why her documentation for Resident #9's bilateral heels had changed from pressure ulcers to arterial ulcers, but that

they were the same wounds.

Review of Resident #9's physician's orders indicated:

- Left heel wound treatment was implemented as recommended.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0686 - DTI right heel (Twice Daily/PRN) Cleanse with saline, apply bactroban followed by alginate, skin prep surroundings, DPD/kling, once daily (of note, this order also indicates twice daily), initiated 2/5/25, instead of Level of Harm - Actual harm Iodosorb, DPD (4x4 gauze), and kling to left heel wound changed daily and PRN which was not implemented as recommended by the consultant Wound PA until 2/18/25, eight days after it was recommended. Residents Affected - Few - The orders failed to indicate the right proximal heel treatment recommendation for Iodosorb, DPD (4x4 gauze), and kling to right proximal heel wound changed daily and PRN. was ever implemented.

Review of Resident #9's medical record failed to indicate any rationale for the right heel and right proximal heel treatments not being implemented as recommended by the consultant Wound PA.

Review of Resident #9's consultant Wound PA progress note, dated 2/17/25, indicated:

- Left heel arterial wound: not improved

- Right heel arterial wound: not improved

- Right heel arterial wound measurements increased in length and depth since last visit on 2/10/25 from 2.0 cm x 5.0 cm x non-measurable depth to 3.0 cm x 4.0 cm x 0.1 cm depth

- Right proximal heel arterial wound healed.

- Recommendations included for left and right heels were implemented as recommended. Right proximal heel was never discontinued because it had never been implemented after recommendation by consultant Wound PA 2/10/25.

Review of Resident #9's nursing progress note, dated 2/19/25, indicated:

- X-ray of right heel came in and was reviewed by NP #1, findings suspicious for calcaneal osteomyelitis, recommend MRI (a non-invasive imaging that visualizes soft tissues and bones in detail, aiding in the diagnosis and treatment of osteomyelitis).

During an interview on 4/7/25 at 9:39 A.M., Nurse #6 said she booked the MRI for 3/4/25.

Review of Resident #9's consultant Wound PA progress note, dated 2/24/25, indicated:

- Recommend consult with PCP (primary care provider) for systemic antibiotic pending culture results.

- Left heel arterial wound: not improved

- Right heel arterial wound: not improved. There is bone exposed (which is a new finding).

- New recurrent right proximal heel arterial wound present.

- Plan: Left heel: Vashe (a type of wound cleanser) (or similar antibacterial wound cleanser), Iodosorb, DPD (4x4 gauze), and kling to the left heel wound changed daily and PRN.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0686 - Plan: Right heel: Vashe (or similar antibacterial wound cleanser), Bactroban, Alginate, DPD, and kling to

the right heel wound changed twice daily and PRN. Level of Harm - Actual harm - Plan: Right proximal heel: Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 Residents Affected - Few gauze) and kling to the right proximal heel wound changed daily and PRN.

Review of Resident #9's physician's orders indicate:

- DTI left heel implemented as recommended by consultant Wound PA on 2/27/25.

- DTI right heel (Twice Daily/PRN) Cleanse with vashe, apply bactroban followed by alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, scheduled once daily (day shift), instead of twice daily as recommended by the consultant Wound PA, initiated 2/27/25.

- DTI right proximal heel (Twice Daily/PRN) Cleanse with vashe, apply Adaptic followed by Alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, scheduled twice (day and evening shift) daily (instead of once daily as recommended by the consultant Wound PA), initiated 2/24/25.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily (instead of being discontinued as recommended by the consultant Wound PA), initiated 1/8/25.

Review of Resident #9's Treatment Administration Record (TAR), dated 2/24/25 through 2/26/25, indicated:

- No wound treatment was documented to have been completed for left heel wound on 2/26/25.

- No wound treatment was documented to have been completed for right heel wound on 2/26/25.

- No wound treatment was documented to have been completed for right proximal heel wound on 2/25/25.

Review of Resident #9's Medication Administration Record (MAR), dated 2/24/25 to 2/25/25, indicated the following order documented as implemented daily.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily (instead of being discontinued as recommended by the consultant Wound PA), initiated 1/8/25.

Review of Resident #9's physician progress note, written by NP #1, dated 2/25/25, indicated:

- XR (X-ray) right heel - findings suspicious for calcaneal osteomyelitis, recommend MRI. Wound examined today, overall worsening this week. Discussed with [consultant Wound PA] and agrees with proactive treatment. Will start rocephin 1g IM (intramuscular) pending wound culture results and toiler further IV antibiotics. MRI has been scheduled 3/4/25 at 8 A.M. Wound tx (treatment)- Vashe (or similar antibacterial wound cleanser), Bactroban, Alginate, DPD (4x4 gauze), and kling to right heel wound changed twice daily.

-This physician progress note does not include any changes to left heel wound treatment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0686 Review of Resident #9's Treatment Administration Record (TAR), dated 2/26/25 to 3/3/25, indicated the following physician's order documented as implemented: Level of Harm - Actual harm - No wound treatment was documented to have been completed for right heel wound on 2/26/25. Residents Affected - Few - DTI right heel (Twice Daily/PRN) Cleanse with vashe, apply bactroban followed by alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, implemented once daily (instead of twice daily as ordered by NP #1) from 2/27/25 to 3/3/25.

Review of Resident #9's Medication Administration Record (MAR), dated 2/26/25 to 3/3/25, indicated the following order documented as implemented daily.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily (instead of being discontinued as recommended by the consultant Wound PA and NP #1), initiated 1/8/25.

Review of Resident #9's nursing progress note, dated 3/1/25, indicated:

- Continued on Amoxicillin (an antibiotic medication) 500-125 mg (milligrams) for bacterial infection. Also, he/she received Doxycycline 200 mg for wound infection.

Review of Resident #9's nursing progress note, dated 3/3/25 at 12:08 P.M., indicated:

- Resident's appointment [MRI] has been cancelled, may re-schedule if residents' health dictates.

Review of Resident #9's consultant Wound PA progress note, dated 3/3/25 at 1:09 P.M., indicated:

- Resident #9 is currently on antibiotics for wound infection.

- X-ray results of the right heel noted findings suspicious for calcaneal osteomyelitis, recommend MRI. Per Nursing staff MRI is pending.

- Wound culture of the right heel revealed moderate growth of mixed gram positive organisms consistent with normal skin flora. Moderate growth of multiple gram negative organisms.

- Left heel arterial wound: Not improved. increased in size

- Right heel arterial wound: Improved. There is bone is exposed.

- Right proximal heel arterial wound: Not improved.

Review of Resident #9's physician progress note, written by NP #1, dated 3/3/25 and time of visit undocumented, indicated:

- Continues on augmentin, doxycycline for R (right) calcaneal osteo (osteomyelitis).

- MRI has been scheduled for 3/4/25 at 8 am.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0686 - Wound tx (treatment)- Vashe, Bactroban, Alginate, DPD (4x4 gauze), and kling to right heel wound changed twice daily. Level of Harm - Actual harm - This physician progress note does not include any changes to left heel wound treatment. Residents Affected - Few

Review of Resident #9's physician's order indicated:

- DTI right heel (Twice Daily/PRN) Cleanse with vashe, apply bactroban followed by alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, scheduled once daily (day shift) (instead of twice daily as ordered by NP #1), initiated 2/24/25.

Review of Resident #9's Treatment Administration Record (TAR), dated 3/3/25 to 3/5/25, indicated the following physician's order documented as implemented:

- DTI right heel (Twice Daily/PRN) Cleanse with vashe, apply bactroban followed by alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, implemented once daily (day shift) (instead of twice daily as ordered by NP #1) from 3/3/25 to 3/5/25.

Review of Resident #9's physician's orders indicated:

- DTI left heel implemented as recommended by consultant Wound PA on 3/3/25.

- DTI right proximal heel (Twice Daily/PRN) Cleanse with vashe, apply Adaptic followed by Alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, scheduled twice daily (instead of once daily), initiated 2/24/25.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA and ordered by NP #1.

Review of Resident #9's Treatment Administration Record (TAR), dated 3/3/25 to 3/6/25, indicated the above order for the right proximal heel was documented as implemented two times each day, instead of once daily as ordered by NP #1.

Review of Resident #9's Medication Administration Record (MAR), dated 3/3/25 to 3/5/25, indicated the following order documented as implemented daily.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA and ordered by NP #1.

Review of Resident #9's medical record indicated he/she had been transferred and admitted to the hospital

on 3/6/25 for bilateral heel osteomyelitis.

Review of Resident #9's hospital discharge summary, dated 3/17/25, indicated:

- Hospital Course: Bilateral heel wounds, necrotic, decubitus ulcers (pressure ulcers) with right heel osteomyelitis and left heel osteomyelitis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0686 - Summary: Pt (patient) remains for medical management of bilateral heel wounds, necrotic, decubitus ulcer with MRI evidence of bilateral calcaneal osteomyelitis, receiving IV (intravenous) IVF (intravenous fluids) and Level of Harm - Actual harm IV abx (antibiotics).

Residents Affected - Few Review of Resident #9's medical record indicated he/she was readmitted to the facility 3/17/25.

Review of Resident #9's nursing admission note, dated 3/17/25, indicated:

- During his/her hospital stay MRI revealed R (right) heel osteomyelitis.

- Wounds to BLE (bilateral lower extremities).

Review of Resident #9's consultant Wound PA progress note, dated 3/24/25, indicated:

- Left heel arterial ulcer: Improved.

- Right heel arterial ulcer: Not improved.

- Right proximal heel arterial ulcer appears healed.

- Plan: Left heel: Vashe (or similar antibacterial wound cleanser), Iodosorb, DPD (4x4 gauze), and kling to

the left heel wound changed daily and PRN.

- Plan: Right heel: Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze), and kling to the right heel wound changed daily and PRN.

Review of Resident #9's physician's orders indicated:

- Left heel (Daily/PRN) Cleanse with wound vashe, apply skin prep to surroundings, apply adaptic to wound bed, followed by iodosorb, lightly pad with 4x4 gauze, secure with kerlix/paper tape, once daily, initiated 3/25/25, instead of Vashe (or similar antibacterial wound cleanser), Iodosorb, DPD (4x4 gauze), and kling to

the left heel wound changed daily as recommended by the consultant Wound PA.

- Right heel (Daily/PRN) Cleanser with wound vashe, apply skin prep to surroundings, apply Adaptic to wound bed, followed by alginate, lightly pad with 4x4, secure with kerlix/paper tape, once daily, initiated 3/25/25.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.

Review of Resident #9's Medication Administration Record (MAR), dated 3/24/25 to 3/30/25, indicated the following order documented as implemented daily.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.

Review of Resident #9's record failed to indicate any rationale for initiation of adaptic in left heel treatment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0686 Review of Resident #9's consultant Wound PA progress note, dated 3/31/25, indicated:

Level of Harm - Actual harm - Left heel arterial ulcer: Improved.

Residents Affected - Few - Right heel arterial ulcer: Improved.

- Plan: Left heel: Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze), and kling to the left heel wound changed daily and PRN.

- Plan: Right heel: Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze), and kling to the right heel wound changed daily and PRN.

Review of Resident #9's physician's orders indicated:

- Left heel (Daily/PRN) Cleanse with wound vashe, apply skin prep to surroundings, apply adaptic to wound bed, followed by iodosorb, lightly pad with 4x4 gauze, secure with kerlix/paper tape, once daily, initiated 3/25/25, instead of Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze), and kling to the left heel wound changed daily as recommended by the consultant Wound PA.

- Right heel (Daily/PRN) Cleanser with wound vashe, apply skin prep to surroundings, apply Adaptic to wound bed, followed by alginate, lightly pad with 4x4, secure with kerlix/paper tape, once daily, initiated 3/25/25.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.

Review of Resident #9's Medication Administration Record (MAR), dated 3/31/25 to 4/7/25, indicated the following order documented as implemented daily.

- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.

Review of Resident #9's Treatment Administration Record (TAR), dated 4/5/25 to 4/7/25, indicated:

- Left heel: Cleanse with wound vashe, apply adaptic, alginate, DPD, and kling to left heel wound, once daily, initiated 4/2/25 and discontinued 4/5/25.

- Left heel: Cleanse with wound vashe, apply iodosorb, DPD, kling to left heel wound, once daily, initiated 4/5/25.

- Audit history of Left heel treatment order initiated 4/5/25 indicated it was input by the Director of Nursing (DON).

Review of Resident #9's medical record failed to indicate any rationale for wound order change on 4/5/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0686 During an interview on 4/8/25 at 11:07 A.M., the DON said she did not contact the provider to obtain any orders to change the left heel wound treatment. The DON said she thinks it's because she saw iodosorb Level of Harm - Actual harm being used so she may have just added it.

Residents Affected - Few Review of Resident #9's consultant Wound PA progress note, dated 4/7/25, indicated:

- Left heel arterial ulcer: not improved.

- Left heel arterial wound measurements increased in length since last visit on 3/31/25 from 3.0 cm length x 3. 7 cm width x non-measurable depth to 3.8 cm length x 3.7 cm width x 0.1 cm depth.

- Right heel arterial ulcer: improved.

During an interview on 4/7/25 at 9:03 A.M., Nurse #5 said the nurses on the floor are not usually involved in transcribing treatment recommendations from the consultant Wound PA. Nurse #5 said the DON is responsible for following up on consultant Wound PA recommendations.

During an interview on 4/7/25 at 11:47 A.M., the consultant Wound PA said she expects physician's orders to be implemented according to her recommendations, unless the attending physician or nurse practitioner decline. She said she expects that they would address and document any rationale for the wound treatment recommendations not being implemented as she recommended based on the facility's policy.

During an interview on 4/7/25 at 2:32 P.M., the Regional Nurse said the iodosorb that was initiated 1/8/25 was never discontinued but should have been multiple times. The Regional nurse said wound orders should be implemented and completed following the physician's order.

During an interview on 4/8/25 at 8:55 A.M., Resident #9's Nurse Practitioner (NP) #1 said the consultant Wound PA sends her wound progress notes with recommendations to the facility and she expects the facility to implement them according to the consultant Wound PA's treatment recommendations. NP #1 said she rarely disagrees with the wound treatment recommendations and if she did, the rationale for not implementing should be documented in the record. NP #1 said she is rarely notified regarding wound orders, unless there is a significant concern. NP #1 says she expects the consultant Wound PA to manage the wounds and if the facility does not implement her recommendations as recommended it could cause a decline in the wound or wound infection.

During an interview on 4/8/25 at 9:36 A.M., The DON said she expects wound treatment orders to be transcribed directly into the physician's orders according to the consultant Wound PA's treatment recommendations. The DON said every wound treatment recommendation should be implemented as recommended, and if for some reason it was not, the rationale should be documented in the medical record.

During an interview on 4/11/25 at 11:08 A.M., the DON said wound treatment orders should be implemented at the frequency the physician orders. The DON said if a dressing is implemented too frequently or not frequently enough it puts the wound at risk for deterioration or infection.

Refer to

F-F880.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41456

Residents Affected - Few Based on observations, record review, and interview, the facility failed to ensure that the resident environment remained free of accident hazards for two Residents (#149 and #88) out of a total sample of 23 residents. Specifically:

1. For Resident #149, the facility failed to implement fall interventions after a fall.

2. For Resident #88, the facility failed to ensure that the Resident was wearing a smoking apron as indicated

in the medical record while the Resident was smoking.

Findings include:

1. Resident #149 was admitted to the facility in January 2025 with diagnoses of falls resulting in a vertebral fracture and dementia.

Review of Resident #149's most recent Minimum Data Set (MDS) indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff had assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #149 required substantial to maximal assistance with self-care and mobility tasks.

Review of the incident report dated 2/2/25 indicated the following:

-Witnessed fall in the main dining room. Resident was ambulating with CNA's back to the main dining room

after toileting. Resident crossed (his/her) feet while walking and slipped to the floor. CNA assisted resident to

the floor, no apparent injuries noted. Resident ambulating at baseline. No c/o (complain of) pain.

Review of Resident #149's fall care plan indicated the following interventions:

-Rehab evaluate and treat as ordered or PRN (as needed), initiated 1/14/25.

-Ensure proper placement of feet prior to ambulation, initiated 2/2/25.

Review of the therapy screen log book for 2025 failed to indicate therapy had screened Resident #149 after

this fall.

During an interview on 4/8/25 at approximately 2:30 P.M. the Director of Rehabilitation said she was unaware Resident #149 sustained a fall on 2/2/25 and never received a referral from nursing to evaluate the Resident.

Review of the Nurse Practitioner note dated 2/6/25 failed to indicate the Nurse Practitioner was notified of

this fall.

Review of the incident report dated 3/23/25 indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0689 -Resident fell off the wheelchair, assessed for injuries, sweelings (sic) and bruises and non (sic) found. (He/she) was helped off the floor and back into the wheelchair. Level of Harm - Minimal harm or potential for actual harm Review of Resident #149's fall care plan indicated the following interventions:

Residents Affected - Few -Rehab evaluate and treat as ordered or PRN (as needed), initiated 1/14/25.

-1:1 (one to one) supervision when out of bed, initiated 3/27/25.

-1:1 supervision for 24 hours. Increase close supervision. MD evaluation. Fall, initiated 3/23/25.

-Resident to be in common areas when awake, initiated 3/23/25.

Review of the 1:1 log book for Resident #149 indicated the following:

-The book failed to indicate 1:1 supervision was completed on four days from 3/27/25 - 3/30/25.

-On 3/31/25, 1:1 supervision was only completed from 11:00 P.M. to 11:45 P.M.

-On 4/5/25, 1:1 supervision was only completed from 3:00 P.M. to 11:00 P.M.

-On 4/6/25, 1:1 supervision was only completed from 12:00 A.M. to 9:00 A.M., and 3:00 P.M. to 11:00 P.M.

-On 4/7/25, 1:1 supervision was not completed from 9:45 A.M. to 3:00 P.M.

-On 4/8/25, 1:1 supervision was not completed from 9:45 A.M. to 3:00 P.M.

During an interview on 4/9/25 at 8:34 A.M., Nurse Practitioner (NP) #1 said she was not made aware of Resident #149's fall on 2/2/25. NP #1 said she would expect all residents to be screened by therapy services when a fall occurs and was unaware Resident #149 was not screened by therapy after the fall on 2/2/25. NP #1 said she would expect all fall interventions to be in place at all times to prevent further falls.

During an interview on 4/9/25 at 11:58 A.M., the Director of Nursing (DON) said after a resident falls at the facility, the staff must complete a fall assessment and implement a new care plan intervention for prevention of further falls immediately. The DON said the nursing staff must also notify the physician or nurse practitioner of the fall and therapy must provide a screen for every fall. The DON said she expects all fall care plan interventions to be in place at all times to prevent further falls from occurring.

45984

2. Review of the facility policy titled Smoking Policy - Residents, dated and revised March 2024, indicated the following:

- Prior to, and upon admission if the facility is a smoking facility, residents shall be informed of the facility smoking policy, including designated smoking areas and smoking times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0689 - The resident will be evaluated upon admission and/or when a resident chooses to smoke, to determine the resident's ability to smoke safely. Level of Harm - Minimal harm or potential for actual harm Review of the document titled Resident Smoking Guidelines, undated, indicated the following:

Residents Affected - Few - Anyone considered to be a smoking risk will be required to utilize appropriate safety devices. If a resident refuses to use safety devices smoking privileged will be revoked.

- Admission and quarterly smoking assessments will be done for safety.

- Protective aprons will be worn per resident smoking assessment.

Resident #88 was admitted to the facility May 2024 with diagnoses including atrial fibrillation, coronary atherosclerosis and post-traumatic stress disorder.

Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE REDACTED] indicated the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition.

The surveyor made the following observation:

- On 4/6/25 at 1:23 P.M., Resident #88 was observed in the courtyard smoking. Resident #88 was not wearing a protective apron while smoking.

- On 4/7/25 at 9:09 A.M., Resident #88 was observed in the courtyard smoking. Resident #88 was not wearing a protective apron while smoking.

Review of Resident #88's Kardex (a form indicating the level of care a resident needs) indicated the following under the safety section: Apron use while smoking if indicated.

Review of Resident #88's most recent Smoking Evaluation dated 2/18/25 indicated the following:

- Protective Smoking Equipment (describe): Apron.

Review of Resident #88's smoking care plan, dated 5/22/24 indicated the following intervention: Apron use while smoking if indicated.

During an interview on 4/7/25 at 2:27 P.M., the Activities Director said residents get evaluated for smoking by nursing. The Activities Director said residents will have care plans if they smoke and they should be implemented. The Activities Director said we have aprons outside, but residents do not want to wear them, including Resident #88. She then said the Director of Nursing said we cannot force residents to wear aprons since this is their home.

During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said if a resident is evaluated to wear a smoking apron while smoking they should be wearing them. The DON then said the resident refuses to wear one then staff need to be documenting the refusal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or 45984 potential for actual harm Based on observation, record review and interview, the facility failed to maintain acceptable parameters of Residents Affected - Few nutritional status for one Resident (#12) out of a total sample of 23 residents. Specifically, the facility failed to a. obtain weekly weights to monitor the weight for Resident #12 as ordered and b. provide the dietary supplements as indicated by the Registered Dietitian.

Findings include:

Review of the facility policy titled Weight Management, dated and revised April 2019, indicated the following:

- Weights will be obtained weekly X 4 after admission. Subsequent weights will be monthly, unless physician's orders or the resident's condition warrants more frequently as determined by the Interdisciplinary Team (IDT).

- If a resident refuses weighing or circumstances prevent weighing the resident, the IDT will document the reason in the resident's medical record and care plan. Make attempt to weigh resident at another time.

Resident #12 was admitted to the facility in January 2019 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease dysphasia and Barrett's Esophagus without dysplasia.

Review of Resident #12's most recent Minimum Data Set Assessment (MDS) indicated that the Resident has

a Brief Interview for Mental Status score of 15 out of 15 indicting intact cognition. Further review of the MDS indicated that the Resident requires partial/moderate assistance with eating

a. Review of Resident #12's physician's order dated 1/29/25, indicated the following:

- weight every 7 days one time a day every 7 days please weigh on Mondays update md (Medical Doctor) with weight gain >5 lbs. (pounds)

Review of Resident #12's weight summary log indicated the following:

- 2/27/25: 219.4 lbs.

- 3/3/25: 226.4 lbs.

- 3/3/25: 226.4 lbs.

- 3/12/25: 224.0 lbs.

- 3/13/25: 229.0 lbs.

- 3/19/25: 224.9 lbs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0692 Review of Resident #12's February 2025 Treatment Administration Record (TAR) sheet failed to indicate any documented weights for the entire month. Level of Harm - Minimal harm or potential for actual harm Review of Resident #12's March 2025 TAR indicated that the Resident was weighed on 3/5/25, 3/12/25 and 3/19/25. The Resident was not weighed on 3/26/25. Residents Affected - Few

Review of Resident #12's medical record indicated that weekly weights were not obtained four times since

the physician's order was implemented on 1/29/25.

Review of Resident #12's Kardex (a form indicating the level of care a resident needs) indicated the following under the Monitors section:

- Monitor/record/report to MD PRN (as needed) s/sx (signs/symptoms) of malnutrition: emaciation, muscle wasting, significant weight loss: 3lbs. in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months.

During an interview on 4/7/25 at 2:10 P.M., the Registered Dietitian (RD) said she works in the facility two days per week. The RD said the Certified Nursing Assistants (CNA) are supposed to obtain the weights and nursing should validate that weights are being obtained. The RD and surveyor reviewed Resident #12's medical record and the RD said Resident #12's weights are not being obtained as ordered.

During a follow up interview on 4/8/25 at 1:34 P.M. after the surveyor notified the RD of Resident #12's weekly weights not being completed, the RD weighed Resident #12, and he/she weighed 219.8 lbs., 5.1 pounds less than the most recent reweigh on 3/19/25. The RD said she will start adding a soft sandwich to his/her meals.

During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said Resident #12 should be weighed as ordered and if the Resident refuses then staff should be documenting it in the medical record.

b. Review of Resident #12's physician's order dated 3/10/25 indicated the following:

- Frozen Nutritional Treat (or magic cup) with meals 2 each all meals

The surveyor made the following observations:

- On 4/6/25 at 8:44 A.M., Resident #12 was eating breakfast in his/her bed. There were no Magic Cups on his/her tray.

- On 4/6/25 at 12:34 P.M., Resident #12 was eating lunch in his/her bed. There were no Magic Cups on his/her tray.

- On 4/7/25 at 12:30 P.M., Resident #12 was eating breakfast in his/her bed. There were no Magic Cups on his/her tray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0692 - Review of a progress note written by the Registered Dietitian dated 2/20/25 at 2:39 P.M., indicated the following: Several interventions in place to increase his/her kcal/pro (calorie/protein) intake: magic cup/frozen Level of Harm - Minimal harm or nutrition treat BID (twice daily). Recommend to continue all other supplement interventions as ordered. potential for actual harm

Review of Resident #12's Medical Nutrition Therapy Assessment completed by the Registered Dietitian (RD) Residents Affected - Few dated 3/10/25, indicated the following:

- Recommended to Start: Increase FNT (Frozen Nutrition Treat - Magic Cup) to 2 each with all meals.

- Summary of Nutrition Assessment: Resident's current weight shows significant loss x 3, and 6 months ago. Reviewed current interventions of Ensure and frozen nutrition treat. Rt (resident) expressed a preference for frozen nutrition treat and required 2 at each meal.

During an interview on 4/8/25 at 1:34 P.M. after the surveyor notified the RD of Resident #12's weekly weights not being completed, the RD weighed Resident #12, and he/she weighed 219.8 lbs., 5.1 pounds less than the most recent reweigh on 3/19/25. The RD said the Resident should be receiving 2 Magic Cups with meals and she will start adding a soft sandwich to his/her meals.

During an interview on 4/8/25 at 1:44 P.M., Certified Nursing Assistant (CNA) #8 said CNA's look at the Resident's meal tickets to make sure everything is on there and if something is missing we will get it for the Resident.

During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said weight loss interventions should be followed as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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

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

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

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41456 potential for actual harm Based on observations, interviews, policy review, and record review, the facility failed to provide respiratory Residents Affected - Few care services in accordance with professional standards of practice two Residents (#92, and #13) out of a total sample of 23 residents. Specifically:

1. For Resident #92, the facility failed to ensure oxygen was set to the level prescribed by the physician and maintain a clean filter on the oxygen concentrator; and

2. For Resident #13, the facility failed to ensure oxygen was set to the level prescribed by the physician.

Findings include:

Review of the facility policy titled, Oxygen Administration, dated 1/2024, indicated the following:

-Steps in procedure: 6. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

- Preparation: Verify that there is a physician's order in place. Review the physician's orders or facility protocol for oxygen administration.

1. Resident #92 was admitted to the facility in August 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD).

Review of Resident #92's most recent Minimum Data Set (MDS) dated [DATE REDACTED], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated he/she is cognitively intact. The MDS also indicated Resident #93 required partial to moderate assistance with functional daily tasks.

On 4/6/25 at 7:41 A.M., the surveyor observed Resident # 92 in bed receiving oxygen via nasal cannula. The oxygen filter was able to be observed from his/her doorway and was covered in gray dust.

On 4/6/25 at 9:34 A.M., Resident #92 was observed lying in his/her bed wearing an oxygen canula. The oxygen concentrator was observed to be set to 5 liters of oxygen. The oxygen filter was observed to be covered in gray dust. Resident #92 said he/she uses oxygen all the time and he/she should receive 4 liters of oxygen. Resident #92 said he/she does not touch the oxygen machine as the nurses set the machine to the level of oxygen he/she should be receiving.

On 4/6/25 at 11:09 A.M., Resident #92 was observed sitting in his/her wheelchair wearing an oxygen canula.

The oxygen concentrator was observed to be set to 5 liters of oxygen and the filter was covered in gray dust.

On 4/7/25 at 8:19 A.M., and 10:17 A.M., Resident #92 was observed sitting in his/her wheelchair wearing an oxygen canula. The oxygen concentrator was observed to be set to 5 liters of oxygen and the filter was covered in gray dust.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 On 4/8/25 at 8:08 A.M., the surveyor, with Nurse #3, observed Resident #92's oxygen filter on his/her concentrator. Nurse #3 said the oxygen filter is covered with a thick dust and should not be because nursing Level of Harm - Minimal harm or staff should be cleaning the filter weekly. potential for actual harm

On 4/8/25 at 8:25 A.M., the surveyor, with the Corporate Nurse, observed Resident #92's oxygen filter on Residents Affected - Few his/her concentrator. The Corporate Nurse said that the filter was very dirty and should not be.

Review of Resident #92's physician orders indicated the following orders:

- oxygen via nasal canula titrated to maintain O2 (oxygen) sats (saturation) above 90% continuously and PRN (as needed), every shift for hypoxia, initiated 10/22/24

-may titrate oxygen from 3 liters to 2 liters via NC (nose canula) to maintain O2 SAT above 89%, initiated 10/1/24.

Review of Resident #92's respiratory care plan initiated on 10/23/24, indicated the following:

-Administer humidified oxygen as per MD (physician) order.

Review of Resident #92's lab results dated 12/1/24 indicated he/she has a CO2 (carbon dioxide) level of 38 mmol/L (millimoles per liter), which is higher than the normal range of 22-33.

During an interview on 4/7/25 at 10:45 A.M., Nurse #1 said Resident #92 is on continuous oxygen therapy and the oxygen level should be set to what is prescribed by the physician. Nurse #1 then checked the Resident's orders and said the Resident should be on 2-3 liters of oxygen. Nurse #1 said the Resident should not receive more oxygen than ordered due to his/her diagnosis of COPD and more oxygen could create carbon dioxide retention (a rise in his/her carbon dioxide levels). Nurse #1 said she gave Resident #92 his/her medications earlier in the morning and did not check his/her oxygen to ensure it was on the correct setting as ordered.

During an interview on 4/7/25 at 11:45 A.M., the Director of Nursing said oxygen setting should be set to the level prescribed by the physician and the nurses should be checking to ensure the settings are correct at least once a shift. The Director of Nursing said Resident #92 should only be receiving 1-3 liters of oxygen and due to his/her diagnosis of COPD, the Resident should not be receiving oxygen at a higher level due to

the risk of CO2 retention.

45984

2. Resident #13 was admitted to the facility in January 2025 with diagnoses including end stage renal disease, obstructive sleep apnea and chronic respiratory failure.

Review of Resident #13's most recent Minimum Data Set Assessment (MDS) dated [DATE REDACTED] indicated that

the Resident has a Brief Interview for Mental Status score of 13 out of 15 indicating intact cognition. Further

review of the MDS indicated that the Resident requires oxygen therapy.

The surveyor made the following observations:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 - On 4/6/25 at 7:58 A.M., Resident #13 was sitting in his/her wheelchair in his/her room receiving oxygen via nasal cannula. The oxygen machine was set to 4.5 liters. Level of Harm - Minimal harm or potential for actual harm - On 4/7/25 at 11:12 A.M., Resident #13 was sitting in his/her wheelchair in his/her room receiving oxygen via nasal cannula. The oxygen machine was set to 4.5 liters. Resident #13 said he/she has to receive Residents Affected - Few oxygen every day.

- On 4/8/25 at 7:13 A.M., Resident #13 was sitting on the side of his/her bed receiving oxygen via nasal cannula at 4.5 liters.

Review of Resident #13's physician's order dated 2/12/25, indicated the following:

- Oxygen at 1-3 liters/minute via nasal cannula update md (medical director) with elevated oxygen needs as needed for SOB (shortness of breath).

Review of Resident #13's altered respiratory status/difficulty breathing care plan, dated and revised 2/4/25, indicated the following intervention:

- Oxygen setting as ordered

Review of Resident #13's most recent laboratory results dated [DATE REDACTED], indicated the following:

- CO2 (carbon dioxide) 37 mmol/L. The reference range for a normal value is indicated to be between 22-33 mmol/L. This result was flagged as being high.

During an interview on 4/8/25 at 9:02 A.M., Nurse #7 said Resident #13 has trouble breathing so he/she is

on oxygen. Nurse #7 and the surveyor reviewed Resident #13's orders and she said his/her oxygen should be set between 1-3 liters. Nurse #7 said if Resident #13 receives too much oxygen he/she could retain more CO2. Nurse #7 and the surveyor observed Resident #13's oxygen machine and she said it was set at 4.5 liters and it was too high.

During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said Resident #13's oxygen setting was set too high and it should be at the setting as indicated in the physician's order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45984 potential for actual harm Based on record review, and interviews, the facility failed to provide care and services consistent with Residents Affected - Few professional standards of practice for one Resident (#13) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 23 residents. Specifically, for Resident #13, the facility failed to ensure nursing staff documented they obtained blood pressures from his/her arm with the AV fistula (arteriovenous fistula, is when an artery and vein connect directly, allowing blood to flow. This term is interchangeably used with AV shunt.).

Findings include:

Review of the facility policy titled Hemodialysis Access Care, dated and revised November 2017, indicated

the following:

- Guidelines: Steps in the procedure:

4. To prevent infection and/or clotting: Do not use access arm to take blood pressure.

Resident #13 was admitted to the facility in January 2025 with diagnoses including end stage renal disease, obstructive sleep apnea and chronic respiratory failure.

Review of Resident #13's most recent Minimum Data Set Assessment (MDS) dated [DATE REDACTED] indicated that

the Resident has a Brief Interview for Mental Status score of 13 out of 15 indicating intact cognition. Further

review of the MDS indicated that the Resident requires dialysis therapy.

During an observation on 4/6/25 at 7:58 A.M., the surveyor observed Resident #13 to have a dialysis fistula

on his/her left arm. Resident #13 told the surveyor this is where he/she received his/her dialysis.

Review of Resident #13's physician's order indicated the following:

- Dated 3/13/25: No blood pressure/blood draws to be taken in the left arm, every shift.

- Dated 4/4/25: Dialysis three times per week, Monday, Wednesday Friday.

Review of Resident #13's dialysis care plan, dated 1/27/25, indicated the following intervention: Do not draw blood or take B/P (blood pressure) in arm with graft/shunt.

Review of Resident #13's blood pressure vitals history indicated that staff had documented obtaining blood pressure readings on Resident #13's left arm (where the dialysis shunt is) 15 times since the physician's order was given.

During an interview on 4/8/25 at 9:02 A.M., Nurse #7 said staff should not be obtaining blood pressure readings on Resident #13's left arm as they would be making a mistake by doing so.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0698 During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said staff should not be obtaining blood pressure on Resident #13's left arm, it should be done on his/her right arm. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0699 Provide care or services that was trauma informed and/or culturally competent.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43846 potential for actual harm Based on record review and interview, the facility failed to ensure a comprehensive person-centered plan of Residents Affected - Few care was developed for Trauma-Informed Care for two Residents (#57 and #88), who were admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 23 residents.

Findings include:

Review of the facility policy titled Trauma Informed Care, dated October 2019, indicated: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. Trauma-informed care is culturally sensitive and person-centered. Reduce or eliminate unnecessary stimuli.

1. Resident #57 was admitted to the facility in July 2023 with diagnoses that included Post Traumatic Stress Disorder, dementia, frontotemporal neurocognitive disorder, and depression.

Review of Resident #57's most recent Minimum Data Set (MDS) assessment, dated 3/27/25, indicated he/she scored a 00 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she has a diagnosis of PTSD.

Review of Resident #57's social services assessment, dated 3/27/25, indicated Resident has a history of PTSD and behavioral issues, which are being addressed via medication.

Review of Resident #57's PTSD care plan, revised 3/17/25, indicated an intervention put into place on 11/13/23 to Determine best coping strategies that has worked in the past to help the resident cope with traumatic event. Further review of the care plan failed to identify triggers and coping strategies for the Resident.

During an interview on 4/6/25 at 12:40 P.M., Family Member #1 said his/her family member has been through a lot in their life. Family Member #1 said she is more than willing to talk to the facility about their family member.

During an interview on 4/7/25 at 2:00 P.M., the Social Worker said triggers should be on the PTSD care plan so staff know what will set that resident off. The Social Worker said she has not discussed triggers or coping strategies with his/her family who is her responsible party and Guardian.

During an interview on 4/8/25 at 2:14 P.M., the Director of Nursing said a resident who has a diagnosis of PTSD should have a care plan in place with triggers so staff are aware.

45984

2. Resident #88 was admitted to the facility May 2024 with diagnoses including atrial fibrillation, coronary atherosclerosis and post-traumatic stress disorder (PTSD).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0699 Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE REDACTED] indicated the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further Level of Harm - Minimal harm or review of the MDS indicated Resident #88 has a post-traumatic stress disorder diagnosis. potential for actual harm

Review of Resident #88's MDS dated [DATE REDACTED] indicated that the Resident has a post-traumatic stress Residents Affected - Few disorder diagnosis.

Review of Resident #88's Behavioral Health evaluation completed by the Nurse Practitioner, dated 6/6/24, indicated the following:

- HPI (History of Present Illness): PTSD

Review of Resident #88's Behavioral Health evaluation completed by the Nurse Practitioner, dated 8/8/24, indicated the following:

- HPI: Reports worsening anxiety and depression. Endorses flashbacks and nightmares related to PTSD.

- Psychiatric History: SI (Suicidal Ideation) Details: I think I tried years ago when I was depressed.

- Clinical Assessment: Endorsed nightmares and flashbacks reported to PTSD.

Review of Resident #88's current, active care plans failed to indicate that a personalized, resident-focused care plan was implemented for PTSD.

During an interview on 4/7/25 at 1:55 P.M., the Social Worker said when residents are admitted to the facility

the staff do an in-depth evaluation. The Social Worker continued to say a part of that evaluation is asking if

the Resident has PTSD or trauma history and if so, a personalized care plan indicating triggers should be developed for the Resident. The Social Worker said she was not aware Resident #88 has endorsed having PTSD and he/she should have a care plan in place.

During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said all residents with a known history or diagnosis of PTSD should have a personalized care plan indicating triggers. The DON said she was not aware Resident #88 had PTSD or that a care plan was not in place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 48990

Residents Affected - Some Based on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to meet the facility-determined minimum for certified nurse assistant (CNA) staff on the weekends.

Findings Include:

Review of the facility assessment, reviewed 3/5/25, indicated:

Direct Care Staffing Ratios:

Unit A: Days 3 CNAs, Evenings 3 CNAs, Nights 2 CNAs.

Unit B: Days 3 CNAs, Evenings 3 CNAs, Nights 2 CNAs.

2nd Floor: Days 4 CNAs, Evenings 4 CNAs, Nights 3 CNAs.

Review of this facility assessment indicated total CNA staffing required for facility from 3/5/25 to 4/9/25 should be: Days 10 CNAs, Evenings 10 CNAs, Nights 7 CNAs.

Review of electronic correspondence given to surveyor from the Director of Operations to the Regional Nurse, dated 4/9/25, indicated:

- The facility assessment was updated in December 2024 and reviewed in QAPI 12/18/24. The staffing requirements by unit prior to the updated assessments were:

A-Unit: Days 2 CNAs, Evenings 2 CNAs, Nights 2 CNAs.

B-Unit: Days 3 CNAs, Evenings 3 CNAs, Nights 2 CNAs.

2nd Floor: Days 4 CNAs, Evenings 4 CNAs, Nights 3 CNAs.

Total: Days 9 CNAs, Evenings 9 CNAs, Nights 7 CNAs

- This electronic correspondence indicates CNA staffing required for 10/1/24 to 3/4/25.

During the recertification survey the surveyors observed concerns with incontinence care not being provided and with odors of urine and/or body odor throughout the second floor and in one room on the first floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0725 During the initial tour of the facility on 4/6/25 beginning at 7:20 A.M., there were multiple concerns reported to

the surveyors by residents. Seven residents and one family member expressed concerns about wishing Level of Harm - Minimal harm or there were more staff in the building. They said they often have to wait for a long time when they use their potential for actual harm call lights. Some of these interviews included:

Residents Affected - Some - One resident who said, I learned to change my own incontinence brief because it takes too long for the call bells to be answered, and I don't want to wait.

- One resident further said there is often not enough staff, especially on the weekends. The call bell takes a long time to answer, usually between a half hour to an hour.

- The family member said the facility is always short staffed especially on the weekends. She said her family member does not receive care and does not get fed his/her meal.

During the Resident Group interview on 4/8/25 at 11:05 A.M., 10 out of 16 residents expressed concerns with low weekend staffing causing long call bell wait times and medications being administered late.

During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for fiscal year (FY) Quarter 1, 2025 (October 1, 2024 - December 31, 2024) was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing.

Review of the weekend staff schedule, dated October 1, 2024, to December 31, 2024, indicated that the facility was staffed below their determined minimum necessary CNAs for 10 weekend shifts. On these days there were no additional nurses scheduled who could assist with CNA duties. The weekend staff schedules indicated the following staffing during this quarter:

- Saturday October 12, 2024: only 6 CNAs on night shift but should have been 7.

- Sunday October 13, 2024: only 5 CNAs on night shift but should have been 7.

- Saturday October 26, 2024: only 8 CNAs on evening shift but should have been 9.

- Saturday November 2, 2024: only 6 CNAs on night shift but should have been 7.

- Sunday November 3, 2024: only 5 CNAs on night shift but should have been 7.

- Saturday November 9, 2024: only 6 CNAs on night shift but should have been 7.

- Sunday November 10, 2024: only 6 CNAs on night shift but should have been 7.

- Sunday November 17, 2024: only 6 CNAs on night shift but should have been 7.

- Sunday November 24, 2024: only 6 CNAs on night shift but should have been 7.

- Sunday December 19, 2024: only 6 CNAs on night shift but should have been 7.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0725 Further review of the weekend staff schedules, dated January 1, 2025, to April 6, 2025, continued to indicate

the facility was staffed below their determined minimum necessary CNAs on 9 weekend shifts. On these Level of Harm - Minimal harm or days there were no additional nurses scheduled who could assist with CNA duties. The weekend staff potential for actual harm schedules indicated the following staffing:

Residents Affected - Some - Saturday January 4, 2025: only 6 CNAs on night shift but should have been 7.

- Sunday January 5, 2025: only 8 CNAs on evening shift but should have been 9.

- Saturday February 1, 2025: only 6 CNAs on night shift but should have been 7.

- Sunday February 16, 2025: only 6 CNAs on night shift but should have been 7.

- Sunday February 23, 2025: only 6 CNAs on night shift but should have been 7.

- Saturday March 8. 2025: only 8 CNAs on evening shift but should have been 10.

- Saturday March 29, 2025: only 6 CNAs on night shift but should have been 7.

- Sunday March 30, 2025: only 8 CNAs on day shift but should have been 10.

- Sunday March 30, 2025: only 9 CNAs on evening shift but should have been 10.

During an interview on 4/07/25 at 9:39 A.M., Nurse #6 said sometimes there is trouble with scheduling/rescheduling appointments because of inconsistent staffing.

During an interview on 4/8/25 at 9:45 A.M., Nurse #5 said she sometimes hears CNAs say they have trouble getting all the care completed because of staffing.

During an interview on 4/9/25 at 8:40 A.M., CNA #6 said she works day shift consistently. CNA #6 said when there are ten CNAs on day shift, they can get everything done, but when there is less the CNAs must rush to get the care done.

During an interview on 4/9/25 at 9:48 A.M, the Scheduler said CNA staffing is currently 9 CNAs on the day shift, 9 CNAs on the evening shift, and 7 CNAs on the night shift (instead of what the facility assessment, dated 3/5/25 indicated). The scheduler said sometimes it's not met because of call outs or because he just can't get the staff. The Scheduler said if the facility is short staffed, CNAs say they feel overworked and that

they must rush through care.

During an interview on 4/9/25 at 9:57 A.M., the Administrator said he would expect staff levels to be met as determined what was required based on the census. The Administrator said he has been at the facility since January 2024 and had never been notified of not meeting the required staffing levels but would have expected to be. The Administrator said he would expect the facility to follow staffing ratios determined to be necessary to provide care in either the facility assessment or determined ratios.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0725 During an interview on 4/9/25 at 12:35 P.M., the Regional Nurse said the facility assessment was reviewed in December 2024 in regard to staffing level required based on the census. The Regional Nurse gave the Level of Harm - Minimal harm or surveyor the above mentioned electronic correspondence that indicated from October 1, 2024, to March 4, potential for actual harm 2025, the CNA staffing for the facility should have been 9 CNAs on day shift, 9 CNAs on evening shift, and 7 CNAs on night shift. The Regional Nurse said the facility assessment was updated 3/5/24 and the staffing Residents Affected - Some was updated to require more based on the increased facility census and should have been 10 CNAs on day shift, 10 CNAs on evening shift, and 7 CNAs on night shift starting 3/5/25 to present.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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

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

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm 48990

Residents Affected - Some Based on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically,

the facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care.

Findings include:

According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice.

Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that

an individual needs to perform work roles or occupational functions successfully.

Review of the comprehensive Facility Assessment Tool, revised 3/5/25, included but was not limited to the following:

- Services Provided Based on Resident Assessment and Care Plans: Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds).

- Staff training/Education and Competencies: The facility uses [an electronic training system] for various training modules, which are assigned and completed throughout the year. Each module includes exam questions at the end to assess the staff's understanding. Additionally, an annual competency fair is conducted, allowing staff to practice and demonstrate required competencies.

- Yearly Education for All Staff: Skin/Wound Care.

Review of the facility's training plan titled 'Annual Licensed Nurse Skills Competencies and Checklists', undated, indicated, but was not limited to:

- Training Plan Description: Developing clinical competency is important for each nurse in order to deliver quality care. This Annual Licensed Nurse training plan is completed with the ADON (Assistant Director of Nursing), Staff Development Coordinator (SDC) or Designee to facilitate the mastery of nursing skills.

- The checklists follow each step of the skill to provide a complete evaluative tool. They are designed to

record an evaluation of each step of the procedure as met or not met.

- Training Plan Module List: Clean a Wound and Apply a Dry Non-Sterile Dressing Skills Checklist, Wound Documentation Skills Checklist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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

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

F 0726 Throughout the recertification survey (4/6/25 through 4/9/25) the surveyors identified multiple concerns regarding wound care. Level of Harm - Minimal harm or potential for actual harm The surveyor reviewed staff education files for wound competencies for five licensed nurses currently working in the facility: Residents Affected - Some - 3 out of 5 nurses failed to have evidence of wound care competencies completed in the last year or upon hire.

During an interview on 4/9/25 at 11:09 A.M., the Regional Nurse said all nurses are required to complete annual competencies for wound care. The Regional Nurse said she reached out to the regional office, who was also unable to locate the missing annual/on hire wound competencies for the above mentioned three nurses.

During an interview on 4/11/25 at 11:23 A.M., The Director of Nursing (DON) said annual competencies and training should be monitored to ensure they are completed, but that there has been a lot of turnover in the staff development role. The DON said the staff development role was vacant about a year ago and was briefly filled in May, June, July and again briefly later in the year. The DON said the role has been being covered by herself and various other staff. The DON was unable to provide the name of a person primarily responsible for monitoring that competencies were completed during the times there was not a staff development nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 48990 potential for actual harm Based on personnel file review and interview, the facility failed to ensure annual performance reviews were Residents Affected - Some completed at least every 12 months for 5 of 5 Certified Nurse Aides (CNAs) personnel files reviewed.

Findings include:

Review of 5 Certified Nurse Aides (CNAs) personnel files, who had been employed by the facility for over 12 months, indicated:

- 5 out of 5 failed to include documentation of an annual performance review.

During an interview on 4/9/25 at 11:34 A.M., the Director of Nursing (DON) said all CNAs are required to have annual performance reviews completed and the documentation of completion should be readily available. The DON said she was unable to locate any of the 5 CNA annual performance reviewed requested by the surveyor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41456 potential for actual harm Based on record review and interviews, the facility failed to ensure one Resident (#8) was free from Residents Affected - Few unnecessary psychotropic medications, out of a total sample of 23 residents.

Findings include:

Review of the facility policy titled, Psychotropic Medication, dated 7/2023, indicated the following:

-To administer and monitor the effects of psychotropic medications when prescribed. Psychotropic medications will be prescribed at the lowest possible dosage and are subject to gradual dose reduction and re-review as needed.

-Dosage is appropriate for the resident and is not in excess of the suggested daily dosage maximum, unless specifically documented by the attending physician.

-The interdisciplinary team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via resident care plan review period the resident, and one indicated, the family or responsible person, will be included in this process prior to the administration of dose.

Resident #8 was admitted to the facility in August 2019 with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, anxiety.

Review of Resident #8's most recent Minimum Data Set (MDS), dated [DATE REDACTED], indicated the Resident scored

a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #8 was dependent on staff for self-care tasks.

Review of Resident #8's physician orders indicated the following order initiated on 7/17/24:

-Zyprexa (an antipsychotic medication) oral tablet 5 MG (milligrams). Give 5 MG by mouth two times a day related to unspecified dementia. Unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; paranoid schizophrenia.

Review of the psychiatrist notes dated 2/13/25, 3/3/25 and 3/27/25 indicated the following:

-Clinical Assessment: MSE (Mental Status Exam) shows Parkinsonian Sx (symptoms) c/w (consistent with) neuroleptic-induced EPS (Extrapyramidal Symptoms are drug-induced movement disorders that occur due to antipsychotic blockade of the nigrostriatal dopamine tracts) SE's (side effects) .Options to reduce EPS at this point include 1) lowering dose of zyprexa, but recent assault makes this untenable; 2) changing to the lowest EPS agent, which would be Seroquel, which has added benefit of lower metabolic SE's; 3) adding Amantadine, which would be preferable to using an ACh agent (neurotransmitter); 4) Adding an ACh agent such as cogentin or benadryl, but this can cause undesirable SE's and increase mortality in elderly .can increase Zyprexa if needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0757 -The recommendation section of the note failed to indicate a recommendation to start Resident #8 on Seroquel. Level of Harm - Minimal harm or potential for actual harm Review of Resident #8's physician orders indicated the following order written on 3/29/25:

Residents Affected - Few -Seroquel (an antipsychotic medication) oral tablet 50 mg (milligrams) give 1 tablet two times a day related to paranoid schizophrenia.

Review of Resident #8's medical record indicated the following:

-Resident #8 has a legal guardian who makes all medical decisions for the Resident

-Resident #8 has a Roger's orders (a judge and legal guardian decide when an antipsychotic medication can be administered). Resident #8's treatment plan did not include Seroquel as an agreed upon medication for

the Resident.

-The medical record failed to indicate Resident #8 or his/her legal guardian was informed of the new order for Seroquel and the risks/benefits of the medication in advance of administration of the medicine.

Review of the Nurse Practitioner noted, dated 4/3/25, indicated the following:

-Today, nursing reports (the Resident) is more lethargic. Yesterday (he/she) was at (his/her) baseline, this morning ate less breakfast than usual and has been sleeping most of the morning. No reports insomnia or irregular sleep patterns overnight period (his/her) VS (vital signs) are stable, a febrile, no hypoxia. BS (blood sugar) 154. (He/she) has no complaints of SOB (shortness of breath) cough, urinary problems, or pain, though ROS (review of symptoms) limited due to (his/her) baseline dementia slash schizophrenia. Review of PCC (electronic medical record) - (he/she) was started on Seroquel 50MG BID (twice a day) on 3/29, unclear reason, otherwise no recent Med changes. Per nursing (he/she) is up in dining room waiting for lunch this afternoon.

-Physical exam: Quite sleepy on exam.

-Plan: nursing reports today that member is more lethargic and sleepy when compared to baseline. Physical exam intact other than member is noted to be lethargic. VS stable, no other complaints. (He/she) Was started on Seroquel 50MG BID 3/29 - unclear reason/no note/no psych rec. Plan hold Seroquel.

During an interview on 4/7/25 at 7:48 A.M., Nurse #2 said she regularly works at the facility and is familiar with Resident #8. Nurse #2 said she had no idea why the Resident was started on Seroquel.

During an interview on 4/7/25 at 11:45 A.M., the Director of Nursing said Resident #8's mood and behavior is very unpredictable. The Director of Nursing said the Psychiatrist wanted to start Resident #8 on Seroquel and he must have spoken with the Nurse Practitioner about the med changes. The Director of Nursing said

she was unaware of the specifics about the recommendation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0757 During an interview on 4/8/25 at 11:07 A.M., Nurse Practitioner (NP) #1 said Resident #8 should never have been started on Seroquel. NP #1 said it was a suggestion from the Psychiatrist, but the Psychiatrist never Level of Harm - Minimal harm or made it a firm recommendation and had acknowledged it was not on the Roger's treatment plan so could not potential for actual harm have been started without consent from the court. NP#1 said Seroquel most likely wouldn't have been effective medication for Resident #8 anyways. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 43846 Residents Affected - Some Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure a medication cart, treatment carts on the first and second floor and the second floor's medication room were locked while a nurse was not present.

Findings include:

Review of the facility policy titled, Storage of Medications, dated 8/20, indicated the following:

-Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access.

On 4/6/25 at 6:47 A.M., the surveyor observed the medication cart on the first floor unlocked and unsupervised. No staff were present at the cart, the surveyor was able to access the cart and medications.

On 4/6/25 at 7:18 A.M., the surveyor observed the medication room on the second floor unlocked and unsupervised. The surveyor was able to access the medication refrigerator that had multiple medications in it.

On 4/6/25 from 7:18 A.M. to 12:54 P.M., the surveyor observed the treatment cart on the second floor unlocked and unsupervised outside of resident rooms. No staff were present at the cart, the surveyor was able to access the cart. The nurse was not present at the nurses station.

On 4/6/25 at 11:45 A.M. the surveyor observed a first floor treatment cart unlocked and unsupervised next to

the visitors bathroom and staff bathroom. No staff were present at the cart, the surveyor was able to access

the cart.

On 4/7/25 at 7:01 A.M., the surveyor observed the medication room on the second floor unlocked and unsupervised. The surveyor was able to access the medication refrigerator that had multiple medications in it. The nurse was not present at the nurses station.

During an interview on 4/8/25 at 8:08 A.M., Nurse #3 said medication rooms, medication and treatment carts should be locked unless a nurse in the room and at the cart.

During an interview on 4/08/25 at 2:14 P.M., the Director of Nursing said she expects medication rooms, medication and treatment carts should be locked unless a nurse is present in the room or at the carts.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41456 potential for actual harm Based on observations, record review and interviews, the facility failed to follow the recommendations of the Residents Affected - Few dentist to ensure a referral was made to the oral surgeon for one Resident (#92) out of a total sample of 23 residents.

Findings include:

Resident #92 was admitted to the facility in August 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD).

Review of Resident #92's most recent Minimum Data Set (MDS) dated [DATE REDACTED], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated he/she is cognitively intact. The MDS also indicated Resident #93 required partial to moderate assistance with functional daily tasks.

During an interview on 4/6/25 at 9:34 A.M., Resident #92 said he/she has been waiting to see the dentist.

The Resident said he/she was supposed to have teeth pulled and have dentures made and no one from the facility has discussed this with him/her. Resident #92 was observed to have several small, broken and brown teeth on the bottom of his/her mouth. Resident #92 said he/she did not have any pain but would really like to have the dental work completed.

Review of Resident #92's oral health care plan dated 9/9/24, indicated an intervention to refer to dentist as needed.

Review of Resident #92's medical record indicated the Resident was seen by the dentist on 3/10/25 with the following recommendations:

-Action required by nursing staff: Refer to oral surgeon eval for extractions of non-restorable dentition - all remaining maxillary and mandibular teeth, F/F (upper and lower) dentures will be fabricated after initial healing.

Review of Resident #92's nursing and physician notes in March and April 2025 failed to indicate the nursing staff was aware of this recommendation, reviewed this recommendation with the physician and made the referral to the oral surgeon.

During an interview on 4/7/25 at 11:45 A.M., the Director of Nursing said all dental visit notes are emailed to her, and she is responsible for ensuring the recommendations are followed. The Director of Nursing was unaware of the recommendation for Resident #92 to be referred to an oral surgeon and could not say if this referral had been made or not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 45984

Residents Affected - Some Based on observation, record review and interview, the facility failed to serve what was listed on the menu for all meals during the survey period. Specifically, the facility failed to ensure residents received milk with their meals as indicated on the menu.

Findings include:

During the survey period, all surveyors observed residents who did not receive any milk as their meal tickets indicated they should with their meals during the survey period.

Review of the facility menu for the duration of the survey period indicated that milk is to be served with all meals.

During an interview on 4/9/25 at 8:41 A.M., the Foodservice Director (FSD) reviewed the menus with the surveyor. The surveyor asked if milk is part of the menu and if every resident should be served it, the FSD responded by saying milk is typically only provided if the resident gets coffee or tea with their meal.

During an interview on 4/9/25 at 9:10 A.M., the Corporate Registered Dietitian (RD) said milk is built into the nutritional breakdown for all menus, therefore it should be served for all residents unless they do not want it or if they have a dietary restriction.

During a follow up interview on 4/9/25 at 12:10 P.M., the Corporate Registered Dietitian provided the surveyor with an audit that she had just completed, it indicated that four residents on the first floor did not receive milk when they should have and three residents on the second floor did not receive milk when they should have.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 45984 potential for actual harm Based on resident group meeting, interview and test tray results, the facility failed to ensure foods provided Residents Affected - Some to the residents were prepared by methods that conserve palatability and are at appetizing temperatures on four of four units.

Findings include:

The facility was unable to provide a policy regarding food temperature palatability.

During the initial Resident screening process, numerous residents voiced concerns and displeasure about

the overall food quality, temperature, and variety they are provided.

During the resident council group meeting on 4/8/25, at 11:05 A.M., 10 out of 16 participating residents complained that the food is always cold and does not taste good.

On 4/8/25, the surveyors conducted test tray audits during lunch on all units of the facility, the results were as followed:

On the first floor A-unit side, the meal cart arrived on the unit at 12:00 P.M., the surveyor received the tray at 12:12 P.M., the following was recorded:

- Stuffed shell pasta with cheese was 120 degrees Fahrenheit and was warm, not hot.

- Salad was 79 degrees Fahrenheit and room temperature. No salad dressing was served with it.

- Cranberry juice was 63 degrees Fahrenheit and warm.

- Ice Cream bar was 22 degrees Fahrenheit and melted all over the tray when it was opened.

On the first floor B-unit side, the meal cart left the kitchen at 12:17 P.M., staff began passing out trays to the residents at 12:21 P.M., the surveyor received the test tray at 12:38 P.M., and the following was recorded:

- Cut-up stuffed shell pasta with cheese was 115 degrees Fahrenheit and was slightly warm, not hot.

- Mixed vegetables were 111 degrees Fahrenheit and slightly warm, not hot.

- Salad Dressing was 73 degrees Fahrenheit, no salad was served with this diet texture.

- Coffee was 118 degrees Fahrenheit and not hot.

- Apple Juice was 58 degrees Fahrenheit and warm

- Ice Cream Bar was 23 degrees Fahrenheit and actively melting as it was opened.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 the second-floor A-unit, the following was recorded:

Level of Harm - Minimal harm or - Stuffed shell pasta with cheese was 120 degrees Fahrenheit and was warm to cool, not hot. potential for actual harm - Salad was warm and not cool. Residents Affected - Some - Salad dressing was 72 degrees Fahrenheit and very warm.

- Apple juice was 58 degrees Fahrenheit and warm.

- Coffee was 113 degrees and lukewarm, not hot.

- Ice cream bar was very soft and melted upon opening.

On the second-floor B-unit, the following was recorded:

- Stuffed shell pasta with cheese was 132 degrees and lukewarm.

- Salad was warm and not cool.

- Salad Dressing was 71 degrees Fahrenheit and warm.

- Ginger ale was 59 degrees and warm

- Coffee was 109 degrees and lukewarm, not hot.

- Ice Cream bar was melting upon opening it.

Durin an interview on 4/8/25 at 12:54 P.M., the Corporate Dietary Personnel said the food should be hotter or colder and it is likely a combination of both the kitchen and tray passing.

During an interview on 4/9/25 at 8:41 A.M., the Foodservice Director said she would expect Residents to be receiving their food at an appropriate temperature and she acknowledged that temperatures were not acceptable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0808 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Level of Harm - Minimal harm or potential for actual harm 45984

Residents Affected - Few Based on observation, record review and interview, the facility failed to provide the prescribed, therapeutic diet for two Residents (#12, #4) out of a total sample of 23 Residents. Specifically:

1. For Resident #12, the facility failed to ensure the Resident was receiving Nectar Thickened Liquids as ordered.

2. For Resident #4, the facility failed to ensure that the Resident was receiving a Dysphagia Mechanical Soft diet and Nectar Thick Liquids as ordered.

Findings include:

1. Resident #12 was admitted to the facility in January 2019 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease dysphasia and Barrett's Esophagus without dysplasia.

Review of Resident #12's most recent Minimum Data Set Assessment (MDS) indicated that the Resident has

a Brief Interview for Mental Status score of 15 out of 15 indicting intact cognition.

Further review of the MDS indicated that the Resident requires partial/moderate assistance with eating.

The surveyor made the following observations:

- On 4/6/25 at 8:44 A.M., Resident #12 was eating breakfast in his/her bed with no staff present. On his/her lunch tray was an unopened packet of powder to make drinks Nectar Thick Consistency. Resident #12 said staff are supposed to put it in his/her coffee but never do. Resident #12 proceeded to drink his/her coffee that was not Nectar Thick consistency.

- On 4/7/25 at 8:02 A.M., Resident #12 was eating breakfast in his/her bed with no staff present. On his/her lunch tray was an unopened packet of powder to make drinks Nectar Thick Consistency. Resident #12 said staff do not open the Nectar Thick Packet most of the time. Resident #12 proceeded to try and open the packet, and he/she was unable to do so. The Resident then took a sip of his/her coffee that was not Nectar Thick consistency.

- On 4/8/25 at 8:26 A.M., Resident #12 was eating breakfast in his/her bed. The packet of Nectar Thick powder was unopened as Resident #12 was eating his/her breakfast.

Review of Resident #12's meal ticket indicated the following: Thick Fluids - Nectar Mildly, Standing orders: 8 fl oz (fluid ounce) coffee decaf Nectar

Review of Resident #12's physician's order dated 3/26/25, indicated the following:

- Nectar Thick Liquids (2 mildly thick) consistency

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0808 Review of Resident #12's Kardex (a form indicating the level of care a resident needs) indicated the following under the Monitors section: Level of Harm - Minimal harm or potential for actual harm - Monitor/document/report PRN (as needed) s/sx (signs/symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, appears concerned at meals. Residents Affected - Few

Review of Resident #12's Speech Therapy Evaluation and Plan of Treatment dated from 1/13/25 through 2/9/25, indicated the following:

- Recommendations: Diet Recs - Liquids = Nectar Thick Liquids.

Review of Resident #12's Medical Nutrition Therapy Assessment completed by the Registered Dietitian (RD), dated 3/10/25, indicated the following:

- Recommend to Continue: Nectar Thick Liquids

During an interview on 4/8/25 at 1:34 P.M., the RD said Resident #12 should be receiving Nectar Thick Liquids. The RD said staff should be pouring the Nectar Thick Powder in the Resident's coffee.

During an interview on 4/8/25 at 1:44 P.M., Certified Nursing Assistant (CNA) #8 said CNA's will open the Nectar Thick Packet for the residents and mix it into their coffee. CNA #8 said we look at the meal ticket to make sure everything is correct.

During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said Resident's diets should be followed as ordered.

2. Resident #4 was admitted to the facility in June 2014 with diagnoses including hemiplegia and hemiparesis, dysphagia and epilepsy.

Review of Resident #4's most recent Minimum Data Set Assessment (MDS) indicated that the resident had a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident is dependent on staff for activities of daily living and requires partial/moderate assistance with eating.

Review of Resident #4's physician's order dated 12/30/24, indicated the following: Regular diet, Dysphagia Mechanical Soft texture, Nectar Thick Liquids (2 mildly thick) consistency.

The surveyor made the following observation:

- On 4/7/25 at 10:52 A.M., Resident #4 was sitting at a table in the dining room. A Certified Nursing Assistant (CNA) approached him/her and asked if he/she wanted any water and a snack. The CNA proceeded to pour Resident #4 a cup of water from a water container on the nursing cart and give the Resident a bag of a Cheez-It snack (a crunchy, crumbly snack). The CNA proceeded to tell the Resident it is salty and she walked away. Resident #4 proceeded to eat the snack and drink the water with no supervision. The CNA did not check the Resident's diet or make the water a Nectar Thick Consistency.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0808 During an interview on 4/7/25 at 2:10 P.M., the Registered Dietitian (RD) said Cheez-Its are not an appropriate snack for someone on a Dysphagia Mechanical Soft diet and they pose a choking risk. The RD Level of Harm - Minimal harm or also said Resident #4 should not be drinking any liquid that is not a Nectar Thick Consistency. potential for actual harm

During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said resident's diets should be followed as Residents Affected - Few ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 45984

Residents Affected - Some Based on observation and interview the facility failed to properly follow food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety.

Findings include:

The surveyor made the following observations during the lunch trayline on 4/8/25:

- At 11:38 A.M., the cook began trayline service, the cook had a visible beard approximately one-inch long and was not wearing a beard net.

- At 11:41 A.M., a diet aide removed disposable gloves and then touched her pants with her bare hands, then touched the oven knobs and then put on a new pair of disposable gloves without washing her hands, thus contaminating her gloves. At 11:44 A.M., the diet aide removed her disposable gloves and used oven mits to remove a tray from the oven. She then put on new disposable gloves without washing her hands, contaminating the gloves. The diet aide then put on new gloves and directly touched bread, contaminating

the bread.

- At 11:59 A.M., the cook left the tray line, opened a door to leave the kitchen and got a new box of disposable gloves with bare hands. The cook then put on a pair of disposable gloves without washing his hands, contaminating the gloves. The cook then touched ready-to-eat salad with the contaminated gloves.

- At 12:03 P.M., the cook left the trayline to obtain a beard net and put it on with bare hands. The cook then put on new disposable gloves without washing his hands, contaminating the gloves. At 12:05 P.M., the cook touched his shirt with the gloved hands, then removed a tray from trayline and brought it to the dish room wearing the same gloves. The cook then removed the gloves, touched his shirt with bare hands and put on new gloves without washing his hands, contaminating the gloves. The cook then opened the refrigerator with

the gloved hands and grabbed salad mix. He then opened the salad mix and touched the ready-to-eat lettuce with the contaminated gloves.

- At 12:14 P.M., the cook touched the telephone with gloved hands and resumed trayline with the contaminated gloves. At 12:15 P.M., the cook removed the gloves and then touched his over-the-ear headphones on his head with bare hands, he then put new gloves on without washing his hands prior, contaminating the gloves, he then resumed trayline.

During an interview on 4/9/25 at 8:41 A.M., the Foodservice Director (FSD) said she expects staff to wash their hands before putting on new gloves and to wash their hands when they leave their station and return.

The FSD said staff should have practiced better hand hygiene during the trayline service.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 48990

Residents Affected - Few Based on observation, record review and interview, the facility failed to accurately document in the medical

record for one Resident (#9) out of 23 total sampled residents. Specifically, for Resident #9, the facility failed to document presence of six bilateral foot wounds in weekly skin evaluations.

Findings include:

Resident #9 was admitted to the facility in November 2024 with diagnoses including diabetes and mild cognitive impairment.

Review of the Minimum Data Set (MDS) assessment, dated 1/23/25, indicated Resident #9 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS indicated Resident #9 had two unstageable pressure ulcers. This MDS also indicated Resident #9 was unable to walk and was dependent on staff for turning in bed, hygiene, and transferred.

Review of Resident #9's entire plan of care related to skin, revised 3/24/25, indicated the Resident had left and right heel arterial ulcers. The entire plan of care failed to indicate the Resident had any other wounds.

On 4/7/25 at 10:36 A.M., the surveyor observed Nurse #5 perform the wound dressing change on Resident #9's bilateral heels. During this observation, there were six additional wounds on the bilateral feet. The following additional wounds were observed on Resident #9's left foot: two dime sized wounds on left lateral foot and one dime sized wound on the left ankle. The following additional wounds were observed on Resident #9's right foot: one dime sized wound on the right lateral foot and two dime sized wounds on the anterior foot. Nurse #5 said all six of these wounds appear to be eschar (necrotic tissue that can develop in wounds). Certified Nurse Assistant (CNA) #7 was present during this observation. Nurse #5 and CNA #7 said these six wounds developed shortly after he/she returned from the hospital (Resident #9 was readmitted to the facility from the hospital on 3/17/25). Nurse #5 said there are no wound treatment orders for these six wounds, and she does not know what type of wounds they are. Nurse #5 said the consultant Wound PA had been responsible for assessing these six wounds weekly.

Review of Resident #9's admission assessment, dated 3/17/25, indicated the following wounds:

- Right Heel, Type Pressure, length 6 centimeters (cm) by 6.2 cm.

- Left Heel, Type: Pressure, length 4.8 cm by 6.5 cm.

- Anterior l. (left) foot, Type: Other (specify), length 1.3 cm by 2.1 cm.

- Left late (lateral), Type: Other (specify), length 1.5 cm by 1.5 cm.

- Medial Left Archille [sic], Type: Other (specify), length 2 cm by 1.8 cm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 - Right heel proximal scab, Type: Other (specify), length 2 cm by 2.1 cm.

Level of Harm - Minimal harm or Review of Resident #9's assessments titled 'Weekly Skin Evaluation', dated 3/20/25, 3/27/25, and 4/3/25, potential for actual harm failed to indicate any wounds in addition to the left heel and right heel pressure ulcers.

Residents Affected - Few Review of Resident #9's medical record failed to include any wound treatment orders, mention of, assessment, or measurements of any wounds other than relating to the left heel and right heel pressure ulcers from 3/18/25 until the surveyor's wound observation on 4/7/25.

During an interview on 4/7/25 at 11:42 A.M., The Director of Nursing (DON) the Resident had additional wounds on his/her feet when they were readmitted from the facility on 3/17/25 and they spoke about the additional foot wounds weekly during risk meeting since his/her readmission. The DON said the six additional foot wounds should have been documented on the weekly skin evaluations but were not.

During a follow up interview on 4/9/25 at 8:07 A.M., the Regional Nurse said she assessed the six additional wounds on Resident #9's bilateral feet and they looked like they were arterial ulcers to her. The Regional Nurse said they should have been documented on the weekly skin evaluations but were not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 48990 potential for actual harm Based on observations, interviews and record review, the facility failed to maintain an infection prevention Residents Affected - Few and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, for Resident #9, the facility failed to ensure staff performed hand hygiene before applying and after removing gloves during wound care.

Findings include:

Review of the facility policy titled 'Handwashing/Hand Hygiene', revised July 2024, indicated, but was not limited to the following:

- Policy: The facility considers hand hygiene the primary means to prevent the spread of infections.

6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations:

e. Before donning (applying) gloves.

i. After handling used dressings, contaminated equipment, etc.

j. After removing gloves.

8. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Resident #9 was admitted to the facility in November 2024 with diagnoses including diabetes and mild cognitive impairment.

Review of the Minimum Data Set (MDS) assessment, dated 1/23/25, indicated Resident #9 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS indicated Resident #9 had two unstageable pressure ulcers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 82 225329 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 225329 B. Wing 04/09/2025

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

Melrose Healthcare 40 Martin Street Melrose, MA 02176

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 On 4/7/25 at 10:36 A.M., the surveyor observed Nurse #5 perform wound dressing change on Resident #9's bilateral heel pressure ulcers. Nurse #5 removed a dressing from right heel wound. Nurse #5 then removed Level of Harm - Minimal harm or gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #5 cleansed the right potential for actual harm heel wound, which had a large amount of tan drainage, with a wound cleanser and gauze. Nurse #5 then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #5 applied Residents Affected - Few skin prep the edges of the wound bed. Nurse #5 then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #5 applied adaptic (wound treatment) and alginate (wound treatment) to the wound bed. Nurse #5 then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #5 applied a dressing to the right heel wound. Nurse #5 then removed gloves and used an alcohol prep pad to clean her hands. Nurse #5 said she forgot hand sanitizer and instead is using alcohol prep pads to sanitize. Nurse #5 then applied new gloves and assisted Resident to reposition in bed. Nurse #5 removed the left heel dressing. Nurse #5 then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #5 cleansed the left heel wound, which had a large amount of tan drainage, with a wound cleanser and gauze. Nurse #5 then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #5 continued to cleanse the left heel wound with wound cleanser. Nurse #5 then removed gloves and used an alcohol prep pad to clean her hands. Nurse #5 applied iodosorb (a wound care gel) and a dressing to the left heel wound. During these wound dressing changes Nurse #5 did not perform any hand hygiene after removing gloves and before applying new ones during six out of eight glove changes. During the other two glove changes, Nurse #5 used alcohol prep pads to sanitize and said this was because she forgot hand sanitizer.

During an interview on 4/7/25 at 11:14 A.M., Nurse #5 said she should have performed hand hygiene during all glove changes but did not.

During an interview on 4/7/25 at 12:06 P.M., the Director of Nursing (DON) said Nurse #5 should have performed hand hygiene by either using an alcohol-based hand rub or washing hands with soap, during all glove changes. The DON said alcohol prep pads are not a substitute for hand hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 82 225329