Hillcrest Commons Nursing & Rehabilitation Center

F-F688.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 51466 potential for actual harm Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living Residents Affected - Few (ADL) care in accordance with assessed needs, goals for care, preferences, and recognized standards of practice for one Resident (#155) out of a total sample of 36 residents.

Specifically, for Resident #155, the facility failed to:

-provide consistent ADL assistance relative to dressing, nail and hand hygiene care when the Resident had bilateral hand contractures and was dependent on staff for bathing, dressing and personal hygiene increasing the risk for skin breakdown and resulting in development of a fungal infection in his/her left hand that required medical treatment.

Findings include:

Review of the facility policy titled ADLs: basic skills needed in regular daily life including ambulating, dressing, bathing, eating), dated 11/14/16, indicated:

-Each Resident will receive the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing, consistent with the Resident's comprehensive assessment and plan of care.

>The care and services for ADL will be based on Resident's ability as identified in the Minimum Data Set (MDS) Assessment, rehab (rehabilitation) evaluation, nursing assessment, and person-centered care plan.

>Assistive Devices and adaptive equipment are provided as needed.

>Resident's abilities, personal choices and self-image are accounted for during ADLs.

Review of the facility policy titled Care of Foot and Nails, dated 2/27/17, indicated but was not limited to the following:

-Resident's need special care to prevent infection, odors, and injury to soft tissue.

> .To provide nail care to promote optimum health, safety and comfort of the Resident, reduce health risk secondary to existing medical condition, and prevent infection.

>Licensed Nurse can delegate to Nursing Assistants the trimming of nails of non-diabetic residents or residents without circulatory impairments. Licensed Nurse can trim the nails of residents with diabetes and circulatory impairments only.

Review of the facility policy titled Skin Integrity Management, revised 5/21/21, indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 -Based on the comprehensive assessment of a resident, the facility must ensure that the resident receives care, consistent with professional standards of practice to prevent pressure ulcer or injury and does not Level of Harm - Minimal harm or develop pressure ulcer or injury unless the individual's clinical condition demonstrates that they were potential for actual harm unavoidable, consistent with CMS requirement and guidance.

Residents Affected - Few >maintain the integrity of our resident's skin, the largest organ in the body which plays a significant factor in their overall health.

>minimize the risks and prevent the occurrence of skin breakdown through initial comprehensive and regular skin assessments.

>develop and implement a comprehensive, person-centered plan of care aimed at maintaining skin integrity, prompt identification, intervention and management of any skin breakdown on accepted clinical standards of practice.

Resident # 155 was admitted to the facility in September 2022, with diagnoses including Anoxic Brain Damage and Cardiac Arrest.

Review of the Minimum Data Set (MDS) Assessment, dated 1/7/25, indicated Resident #155:

-has severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of

a total possible score of 15.

-has no range of motion (ROM) deficits.

-was dependent on the assistance of staff with toileting, personal hygiene, bathing, dressing, turning, repositioning and transfers.

-has diagnoses including Anoxic Brain injury, wound infection, and malnutrition.

-was at risk for pressure ulcers and had one Stage 4 Pressure injury (full thickness tissue loss resulting from pressure) [of the coccyx].

Review of Resident #155's Activities of Daily Living (ADL) Care Plan initiated 9/20/22, effective 1/6/25, indicated:

-alteration in the ability to provide self-care/ perform ADLs, with an anoxic brain injury, bedbound and was dependent on staff.

The ADL Care Plan included the following interventions:

-Provide movement of the extremities during ADL care as tolerated, effective 9/20/22.

-Be alert to non-verbal cues of discomfort: grimace, restless, etc. (et cetera)

Review of Resident 155's At Risk for Skin Breakdown Care Plan, initiated 9/20/22, effective 1/6/25, indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 >was at risk for pressure ulcer development related to bedbound status, impaired mobility, incontinence, dependent on staff, and had a Stage 4 wound on the coccyx upon admission to the facility. Level of Harm - Minimal harm or potential for actual harm The At Risk for Skin Breakdown Care Plan included the following interventions:

Residents Affected - Few -Observation of skin condition during care - report pink, red or open areas to the Nurse, initiated 9/20/22.

-Update Physician of new skin conditions and obtain orders, initiated 9/20/22.

-Avoid/limit skin to skin contact. Use pillows/foam wedges to keep body prominences from direct contact with each other, initiated 9/20/22

On 3/18/25 at 9:12 A.M., the surveyor observed Resident #155 was lying in bed wearing a hospital gown.

The surveyor observed the Resident's right hand was contracted into a fist position, with long, chipped and misshapen fingernails and brown material under the fingernails. The surveyor further observed Resident #155's fingernails on the left hand were long, jagged, with brown material under the fingernails. Resident #155 was unable to open either his/her right or left hand at the surveyor's request.

On 3/19/25 at 2:43 P.M., the surveyor observed that Resident #155 was lying in bed wearing a hospital gown and had a facecloth tucked into the closed fists of both his/her left and right hand.

On 3/20/25 at 8:44 A.M., the surveyor observed that Resident #155 was lying in bed wearing a hospital gown with his/her right and left hands contracted into fists. The Resident was unable to open his/her right or left hand at the surveyors request.

On 3/20/25 at 9:35 A.M., the surveyor observed CNA #6 and Nurse #12 as they attempted to open Resident #155's left hand. During an interview at the time, Nurse #12 said Resident #155's left hand fingernails were thick, very long, and dirty and that she had a hard time viewing the condition of the Resident's skin because of the hand contracture. Nurse #12 said there was a foul odor when the Resident's left palm was exposed. CNA #6 said he could smell something foul when the Resident's left hand was opened. The surveyor was standing at the foot of the Resident's bed at the time and observed a foul odor when Resident #155's left hand was opened. Resident #155 was observed to allow a facecloth to be placed in his/her left hand but not his/her right hand.

During an interview on 3/20/25 at 11:50 A.M., Nurse #12 said the CNA's will often ask a Nurse to help when providing care to the Resident so that a facecloth can be placed into the left and right hands and the Nurse can assess the Resident's skin integrity of both hands. Nurse #12 said that she is not always able to clearly visualize the Resident's palms or between the fingers because of his/her contractures. Nurse #12 said that Resident #155 has had a yeasty odor for a few weeks.

During an interview on 3/20/25 at 11:55 A.M., CNA #6 said he has trimmed Resident #155's fingernails in the past but was unable to recall when fingernail trimming was last done. CNA #6 further said that too much time had passed since the Resident's fingernails had been trimmed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 3/20/25 at 11:56 A.M., Unit Manager (UM) #4 said the CNAs are responsible for trimming fingernails unless directed otherwise by the Nurses. UM #4 said she observed Resident #155's Level of Harm - Minimal harm or fingernails today and the Resident's fingernails were very long and dirty and it was evident that Resident potential for actual harm #155's fingernails had not been trimmed for a long time.

Residents Affected - Few Review of Resident #155's Nurse Practitioner (NP) Progress Note, dated 3/20/25, indicated:

-Bilateral hand contractures were present, along with mild swelling and tenderness on left hand.

-fungal rash was also observed.

Review of Resident #155's Physician orders, dated 3/20/25, indicated:

-Lotrimin Antifungal Cream 1% to left hand twice a day for 14 days for alteration in skin integrity.

During a follow-up interview with UM #4 on 3/20/25 at 2:32 P.M., UM #4 said Resident #155 was evaluated by the Provider, who ordered an antifungal cream for the Resident's left hand due to a fungal infection.

During an interview on 3/21/25 at 7:58 A.M., UM #4 said that CNAs are responsible to perform fingernail care weekly and as needed, but fingernail care had not occurred for Resident #155. UM #4 said that CNAs inform

the Nurses if fingernail care was unable to be performed for any reason.

On 3/21/25 at 8:04 A.M., the surveyor observed Resident #155 lying in bed wearing a hospital gown with a rolled facecloth tucked in both the right and left hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42690 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that one Resident (#215) out Residents Affected - Few of a total sample of 36 Residents received quality of care in accordance with professional standards of practice.

Specifically, for Resident #215, the facility failed to:

-apply ACE bandages on the day shift as ordered to the Resident's bilateral legs to manage swelling and treatment of bilateral leg edema.

-provide care and services that reflected the Resident's preference for application of the ACE bandages when the Treatment Administration Record (TAR) indicated the ACE bandages were applied to the Resident's lower extremites and the Resident was observed without the ACE bandages in place.

Findings include:

Resident #215 was admitted to the facility in December 2024 with diagnoses including Hypertension, Hypothyroidism and lower extremity (leg) edema.

Review of the facility policy titled Documentation -Clinical, revised on 10/31/23, indicated the following:

-Medication and Treatment:

>the Licensed Nurse notes the time and date of all medications and treatments administered on medication administration record or treatment record.

>The Nurse who administers the medication and/or treatment must document it on the residence record.

>If a scheduled medication is withheld or not given as ordered, the Nurse documents this and lists the reason for the resident not receiving the medication and what was done to attempt to administer the medication.

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated Resident #215 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.

Review of Resident #215's March 2025 Physician orders indicated:

-Ace (type of bandage used to control swelling) wraps to bilateral LE (lower extremity) from knee to ankle on day shift. Order date 2/13/25.

-Ace wraps to bilateral LE: remove at bedtime. Order date 2/13/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 During an interview on 3/18/25 at 11:53 A.M., Resident #215 said that both of his/her legs are supposed to be wrapped with ACE bandages daily in the morning and then taken off at night, due to leg edema. The Level of Harm - Minimal harm or surveyor observed Resident #215's legs was not wrapped in ACE bandages at the time. Resident #215 said potential for actual harm if the surveyor were to ask the Nurse why the wraps were not on the Resident's legs, the surveyor would be told it was because the Resident went out to an appointment this morning at 9:15 A.M. Resident #215 said Residents Affected - Few that the Nurse did not offer to wrap his/her legs before leaving for the appointment or when he/she returned from the appointment. Resident #215 further said that he/she could not recall the last time his/her legs had been wrapped.

During an interview on 3/20/25 at 10:45 A.M., Resident #215 said that his/her leg wraps had not been completed at this point in the morning. The surveyor observed that Resident #215 did not have his/her legs wrapped in ACE bandages at the time.

During an interview on 3/24/25 at 2:35 P.M., Nurse #7 said Resident #215 was to have bilateral leg wraps applied daily. Nurse #7 said it was the overnight (11:00 P.M. to 7:00 A.M.) shift's responsibility to put on the leg wraps per the Physician's order. Nurse #7 said the Resident often refused to have the leg wraps put on. Nurse #7 said the Resident did not have the leg wraps on today and she did not know why the leg wraps had not been applied, as she did not receive that information during the shift change over.

Review of Resident #215's March 2025 Treatment Administration Record (TAR) indicated the Resident refused the ACE wraps as indicated by an H with a corresponding note stating, held due to Resident refused

on the following dates: 3/4/25, 3/7/25, 3/11/25, 3/17/25, and 3/19/25.

Further review of Resident #215's March 2025 TAR indicated the ACE wraps had been applied to bilateral LE, as evidenced by a Nurse's signature indicating the order had been followed and completed on the following dates:

-3/18/25 (no leg wraps in place - surveyor observation)

-3/20/25 (no leg wraps in place - surveyor observation)

-3/24/25 (Nurse #7 provided the surveyor notification that the leg wraps were not applied to the Resident's lower extremities)

During an interview on 3/24/25 at 2:36 P.M., the surveyor and Unit Manager (UM) #4 reviewed the current Physician orders and the TAR administration history for March 2025. UM #4 said the Physician orders indicated the leg wraps were supposed to be put on the Resident during the day (7:00 A.M.-3:00 P.M.) shift, not the overnight (11:00 P.M.-7:00 A.M.) shift. UM #4 said she purposely did not put a time on the order, only which shift it should be completed on, to allow some leeway as well as to work with Resident #215 when he/she is available. UM #4 said that the wraps should then be removed before bed. UM #4 said the TAR for today was signed off by Nurse #7, indicating that Nurse #7 had put the leg wraps on Resident #215 this morning (3/24/25). UM #4 said that based on the order and the administration history she would have expected to see the leg wraps on the Resident today, but she did not. UM #4 said if the TAR is signed off with a Nurses' initials and no other notation, it was assumed that the order had been completed and that the leg wraps had been applied. UM #4 further said if the Resident refused or was not available, the Nurse should document H (Held) and document a note with a reason as to why the leg wraps were held.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 On 3/25/25 at 9:38 A.M., the surveyor observed that Resident #215 had bilateral leg wraps on. During an

interview at the time, Resident #215 said the leg wraps were only applied this morning because the state Level of Harm - Minimal harm or was at the facility. Resident #215 further said that he/she was afraid that the leg wraps would not be done potential for actual harm daily after the state left the facility.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm 42761

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide appropriate treatment to prevent further decrease in range of motion (ROM) for one Resident (#123) with limited ROM, out of a total sample of 36 residents.

Specifically, the facility failed to implement a passive ROM (PROM) program to Resident #123's lower extremities when the Resident had bilateral lower extremity contractures and was unable to perform his/her own lower extremity ROM, which increased the Resident's risk for progression of lower extremity contractures and pain.

Findings include:

Review of the American Stroke Association guidance titled Spasticity, https://www.stroke. org/en/about-stroke/effects-of-stroke/physical-effects/spasticity last reviewed 5/30/23, indicated the following:

-Spasticity is a common post-stroke condition that causes stiff or rigid muscles.

-When a muscle cannot complete its full ROM, the surrounding tendons and soft tissue can become tight.

-This makes stretching the muscle much more difficult.

-If left untreated, spasticity can also lead to joints in the arm and leg to be stuck or frozen in an abnormal and possibly painful position. This is called contracture.

-Treatment may include:

>Physical exercise and stretching: Stretching helps maintain full range of motion and prevents permanent muscle shortening.

Resident #123 was admitted to the facility in March 2023 with diagnoses including Cerebrovascular Accident (CVA) with hemiparesis and Contracture of Multiple Sites.

Review of Resident #123's Activities of Daily Living Care Plan, dated 3/6/23, indicated:

-Alteration in ability to provide self-care . due to Arthritis, Degenerative Joint Disease (DJD), CVA with Left Paralysis, . decreased mobility, and generalized weakness.

-Encourage movement of extremities during ADL care if tolerated and applicable as needed.

-The Resident was unable to walk.

-The Resident required a mechanical lift for transfers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0688 Review of Resident #123's Pressure Ulcer (PU) Risk Care Plan, dated 3/6/23, indicated:

Level of Harm - Minimal harm or -at risk for PU development related to . mobility. potential for actual harm -Encourage activity and mobility. Residents Affected - Few -Rehab (Rehabilitation) evaluation as needed.

-Use devices the eliminate pressure on the heels: pillows as needed.

Review of Resident #123's Cognitive Care Plan, dated 5/29/23, indicated:

-compromised insight into his/her physical limitations and care needs.

Review of Resident #123's Splint Care Plan, dated 11/19/24, indicated:

-ROM with care as appropriate.

-Use positioning devices.

-PT . evaluation as ordered.

Review of Resident #123's Physical Therapy (PT) Evaluation, dated 12/9/24, indicated:

-referred to PT for positioning and contracture management.

-Presented with:

-decreased ROM to bilateral lower extremities.

-joint mobility/integrity deficits.

-limitations in ROM.

-muscle disuse/atrophy.

-paralysis/paresis.

-inability to stand.

-The Resident sat almost criss cross in his/her wheelchair due to lower extremity contractures of the hips and knees.

-The Resident's rehabilitation potential was fair due to . supportive caregivers/staff.

-The focus of treatment was adaptation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0688 -The Resident was not fully aware of the extent of his/her diagnosis and prognosis due to cognitive deficit and language barrier. Level of Harm - Minimal harm or potential for actual harm Review of Resident #123's PT Progress Note, dated 12/9/24, indicated:

Residents Affected - Few -The Resident showed heavy amounts of contracture into hip flexion, knee flexion, hip abduction, and ankle plantar flexion.

-PT would attempt to work on lower extremity contracture management and positioning.

Review of Resident #123's Minimum Data Set (MDS) Assessment, dated 1/7/25, indicated:

-Brief Interview for Mental Status (BIMS) score of 13 out of 15 total possible points indicating the Resident was cognitively intact.

-Bilateral lower extremity ROM limitation that interfered with daily function were present.

-was dependent for ADLs and was unable to walk.

-had received PT services over the previous seven days.

Review of Resident #123's PT Note, dated 2/5/25, indicated:

-Discontinuation of PT services due to insurance coverage ending, was discussed with the Resident.

-Goals met and not met were discussed with the Resident.

-Physical Therapist educated Resident #123 to have staff position the Resident better to decrease contractures from forming.

Review of Resident #123's PT Discharge Summary, dated 2/5/25, indicated:

-lower extremity ROM improved.

-to reside long-term in the facility.

-was referred for RNP (Restorative Nursing Program)/FMP (Functional Maintenance Program).

Further review of Resident #123's PT Discharge Summary indicated: concerned with staff carryover as they have never shown ability to properly position [Resident] even with education and they have no desire to work

on contracture management program as there is no carryover. Resident will constantly be a pickup and d/c (discharge) with [Resident] progressively getting more contracted due to no carryover. D/C (Discharge) due to insurance cut and will attempt to pick back up at later date for contracture management program again.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0688 On 3/18/25 at 9:05 A.M., the surveyor observed Resident #123 seated in the Unit One Dining Area, reclined position, in a geri chair (chair equipped with a reclining backrest and elevating leg rests), and his/her lower Level of Harm - Minimal harm or body covered with a sheet. The Resident's legs were both observed to be flexed at the knees and both of the potential for actual harm Resident's knees were directed outward toward the armrests of the wheelchair. The surveyor further observed there was one pillow positioned between the Resident's outer knees and the armrests of the Residents Affected - Few wheelchair.

On 3/20/25 at 8:29 A.M., the surveyor observed Resident #123 seated, reclined in a geri chair in the Unit One Dining Area. Both of the Resident's lower extremities were observed to be flexed at the knees and hips and rotated out toward the armrests of the chair. The outer aspect of the Resident's right foot was observed positioned on the seat of the geri chair and the Resident's right heel was approximately three inches from his/her buttocks. The outer aspect of the Resident's left foot was observed also positioned on the seat of the geri chair.

On 3/20/25 at 9:52 A.M., the surveyor observed that Resident #123 remained in the same position as the previous observation made at 8:29 A.M. During an interview at the time, Resident #123 said that he/she could move his/her left foot a little bit. Resident #123 lifted his/her left foot off of the seat of the geri chair and moved his/her foot slightly with his/her knee and hip still flexed. The Resident was unable to demonstrate movement of his/her right lower extremity when the surveyor asked if he/she was able to move the right leg.

During an interview on 3/20/25 at 10:02 A.M., CNA #3 said that PT worked with Resident #123 recently and had instructed him relative to the Resident's positioning in the geri chair and performing some lower extremity ROM. CNA #3 said that when he cared for the Resident, he provided PROM for the resident's lower extremities and that the Resident sometimes reported pain with PROM. CNA #3 said he did not know whether other staff members provided Resident #123 with lower extremity PROM.

During an interview on 3/20/25 at 3:55 P.M., the Physical Therapist said that he provided PT services to Resident #123 recently and that the Resident's PT services were discontinued on 2/5/25. The Physical Therapist said that the focus of the PT intervention was on lower extremity ROM and positioning, and that

the Resident's contractures were significant. The PT said that he talked with CNA #3 relative to positioning

the Resident in the geri chair and also relative to performing PROM to the Resident's lower extremities. The PT said that he discussed this with CNA #3 because he knew CNA #3 would follow through on the interventions for the Resident. The PT said he did not develop a formal or written PROM for Resident #123 for other staff to implement for Resident #123 when the Resident was discharged from PT services on 2/5/25.

On 3/21/25 at 8:15 A.M., the surveyor observed the following in Resident #123's room:

-Resident #123 was lying in bed, his/her head slightly elevated, with a mechanical lift sling under his/her body.

-Resident 123's knees and hips were flexed and rotated outward so that his/her outer legs were flat against

the mattress.

-Resident 123's right heel was positioned just below his/her buttocks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0688 -Certified Nurses Aides (CNAs) #4 and #5 used the mechanical lift to transfer the Resident from the bed.

Level of Harm - Minimal harm or -While in the air, during transfer, the Resident's right leg was observed fully flexed and was rotated outward potential for actual harm with his/her foot positioned up against his/her buttocks inside of the mechanical lift sling.

Residents Affected - Few -CNAs #4 and #5 assisted Resident #123 into the geri chair, then removed the mechanical lift device.

-CNA #4 then placed a pillow on each side of the Resident's lower extremities, between the Resident's outer knees and armrests of the chair, and one pillow behind the Resident's left heel and under his/her right foot.

-CNA #5 then removed Resident #123 from the room and transported the Resident to the Unit One Dining Area.

During an interview on 3/21/25 at 8:30 A.M., CNA #5 said that Resident #123's lower extremities were contracted and staff would attempt to position the Resident in the geri chair with pillows to reduce the Resident's risk for developing pressure ulcers. CNA #5 said that (Rehabilitation) therapy usually worked with Resident #123 for lower extremity PROM and that she was not sure if therapy was still working with the Resident. CNA #5 said staff would complete PROM program with Resident #123 if a program had been set up by the Physical Therapist. CNA #5 said there was no PROM program in place for staff to complete with

the Resident. CNA #5 further said that if there was a PROM program that staff needed to complete with the Resident, therapy would develop the program and complete an in-service with the staff. CNA #5 said no in-service had been provided to staff relative to lower extremity PROM for Resident #123.

During an interview on 3/21/25 at 8:33 A.M., CNA #4 said that she was not aware of any specified lower extremity PROM program in place for staff to complete with Resident #123. CNA #4 said that she did not provide the Resident with lower extremity PROM.

On 3/25/25 at 10:44 A.M., the surveyor requested to speak to the Rehabilitation Director, but the Rehabilitation Director was unavailable for interview.

During an interview on 3/25/25 at 11:04 A.M., the Director of Nursing (DON) said if a resident could not perform their own ROM, staff would be required to complete PROM with the resident. The DON said that ROM programs carried out for residents by nursing staff would be based on recommendations from Rehab staff. The DON said Rehab staff would use an instruction sheet to educate the staff members responsible for

the resident's care, and once education was completed, the instruction sheet would be provided to the Unit Manager (UM). The DON said the UM would then update the resident's Kardex (document containing information for how to care for each resident) with the specified instructions for the resident to ensure staff caring for the resident had the information needed to effectively carry out the recommendations. The DON said Resident #123's condition warranted individualized instruction for PROM due to the degree of the Resident's contractures.

Review of Resident #123's active Kardex failed to indicate any instructions relative to the Resident's lower extremity contractures or ROM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0688 During a follow-up interview on 3/25/25 at 11:14 A.M., the PT said when he provided PROM to Resident #123, he instructed the Resident on the level of discomfort that may be expected as well as what symptoms Level of Harm - Minimal harm or would indicate when to stop applying stretch to the Resident's lower extremity contractures. The PTsaid that potential for actual harm it was important to know when to stop applying passive stretch to the contractures to avoid causing muscle damage and an inflammatory response. The PT said that some CNAs could be expected to perform PROM Residents Affected - Few properly and some CNAs may need more instruction if they do not know how much stretch to apply to a contracted joint. The PT said that no formal education relative to lower extremity PROM was provided to staff responsible to care for Resident #123. The PT further said that concerns with PROM not being provided by staff included further progression of contractures and pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42741 potential for actual harm Based on interview, and record review, the facility failed to provide therapeutic diets as ordered by the health Residents Affected - Some care Provider for nutrition and hydration management for four Residents (#163, #89, #125, and #40) out of a total sample of 36 residents.

Specifically,

1. For Resident #163, the facility failed to ensure a nutritional supplement was administered as ordered by

the Physician after the Resident had a significant weight loss potentially resulting in a further weight decline.

2. For Resident #89, the facility staff failed to establish an accurate fluid plan as ordered by the Physician and inconsistently recorded the total daily fluid intake, placing the Resident at risk for fluid volume overload and related complications when more than the fluid restricted limit was consumed.

3. For Resident #125, the facility failed to review the Physician's order and accurately monitor the Resident's fluid intake for the Resident who was on dialysis.

4. For Resident #40, the facility failed to accurately assess 24-hour fluid amounts when a fluid restriction was ordered by the Physician for the Resident who was on dialysis.

Findings include:

1. Review of the facility policy titled Nutrition Management, revised 9/30/24, indicated the following:

>Policy:

--Residents will receive care and services to ensure acceptable parameters of nutrition status are maintained to the extent possible as indicated by the resident's clinical condition.

-Residents will receive a therapeutic diet when indicated.

-Nutritional assessment and care planning will be completed by the Interdisciplinary team.

-Staff will consistently observe and monitor residents for changes and implement revisions to care plan as needed.

>Purpose: .

--To recognize, evaluate, and address the nutritional needs of every resident, including, but not limited to, the resident at risk or currently experiencing impaired nutrition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 -To provide a therapeutic diet that takes into account he resident's clinical condition and preferences, when there is a nutritional indication. Level of Harm - Minimal harm or potential for actual harm >Procedure:

Residents Affected - Some - .Review dietician's recommendations.

-Obtain orders per recommendations.

-If Medical Doctor (MD) does not want to follow recommendations, document explanation in nursing note.

Resident#163 was admitted to the facility in December 2024 with diagnoses including Alzheimer's Disease.

Review of the recent comprehensive Minimum Data Set (MDS) Assessment, dated 2/14/25, indicated Resident #163:

-required substantial to max assist to eat his/her meals.

-had severely impaired long term memory and short term memory.

-was coded as having a significant weight loss of 5% or more in the last month or of 10% or more in the last six months.

Review of the Vital Parameters Report dated 3/24/25, indicated the following weights for Resident #163:

-8/2/24: 117.2 pounds (lbs)

-9/10/24: 115.6 lbs

-10/8/24: 111.8 lbs

-11/5/24: 108.9 lbs

-12/3/24: 108.2 lbs

-1/3/25: 105.6 lbs

-1/10/25: 92 lbs

-2/1/25: 103 lbs (12.12% weight loss in six months from 8/2/24 to 2/1/25)

-3/3/25: 84 lbs

-3/4/25: 83 lbs (19.42% weight loss in one month from 2/1/25 to 3/4/25)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 the Dietary Progress Note dated 1/31/25, indicated Resident #163:

Level of Harm - Minimal harm or -had a significant weight loss of 14.9% in one month and a 17.71% weight loss in three months. potential for actual harm -had a Dietician recommendation to provide Boost Very High Calorie (VHC-a nutritional drink) after each Residents Affected - Some meal if intake was less than 50%.

Review of the Dietary Progress Note dated 2/12/25, indicated Resident #163:

-had significant weight loss.

-oral (PO) intake.

-continue with current recommendations as ordered.

Review of Resident #163's March 2025 Physician's orders indicated:

-Supplement: Boost VHC Vanilla 8 ounces (oz) box/can, one box/can as needed (PRN). Provide Boost VHC (vanilla only) after each meal if intake is less than 50%. Start date 2/1/25.

Review of Resident #163's Meal Intake Report indicated:

-February 2025: the Resident ate less than 50% for 69 out of 84 meals.

-March 2025: from 3/1/25 through 3/19/25, the Resident ate less than 50% for 17 out of 27 meals.

Review of Resident #163's February 2025 and March 2025 Medication Administration Records (MARs) failed to indicate documentation that Resident #163 was administered Boost VHC after meals when he/she had consumed 50% of less of the meal.

Review of the Dietary Progress Note dated 3/13/25, indicated Resident #163:

-triggered for significant weight loss (loss of 23% in one month),

-was prescribed 4 oz. Boost Breeze (juice based nutritional supplement) twice daily and house supplement 237 milliliters (equivalent to 8 oz) as needed (PRN) for poor PO intake

-consumption for this supplement is unknown.

During an interview on 3/20/25 at 11:35 A.M., the surveyor and Nurse #2 reviewed Resident #163 Physician's orders and Nurse #2 said Resident #163 had an order for Boost VHC vanilla after meals if the Resident's intake was less than 50% at each meal. Nurse #2 said if there was no documentation on the MAR indicating a Boost VHC vanilla was administered then the Boost VHC vanilla had not been offered. Nurse #2 further said Resident #163 did not like the Boost VHC vanilla and preferred the Boost Breeze.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 During an interview on 3/20/25 at 11:59 A.M., the Director of Nursing (DON) said if Resident #163 had an order in place for Boost VHC vanilla after meals if he/she did not consume 50% or more of the meal, nursing Level of Harm - Minimal harm or staff should have been offering the supplement to the Resident as ordered. potential for actual harm

During an interview on 3/20/25 at 12:21 P.M., Nurse #2 said she had not offered Resident #163 any Boost Residents Affected - Some VHC vanilla when she worked on the unit and was unaware of the order until she reviewed the Resident's chart with the surveyor. Nurse #2 said the process for new dietary orders was that the Dietician would let the Unit Manager (UM) know, the UM would then get the order and update the staff regarding the new dietary order. Nurse #2 said the staff member who assisted Resident #163 during meals, would then provide the Nurse with a meal intake percentage after each meal. Nurse #2 said nursing should have administered the Boost VHC vanilla as ordered, and it did not appear to have been administered as ordered. Nurse #2 said Resident #163 had recently lost weight.

During an interview on 3/20/25 at 1:49 P.M., the Dietician said she recommended Resident #163 to be administered Boost VHC as he/she had been losing weight and was comfort care with the goal of trying to stabilize or slow the weight loss. The Dietician said an order was put into place on 2/1/25 for the Resident to receive Boost VHC vanilla after meals if he/she ate less than 50% of the meal. The Dietician said nursing staff should have been administering Boost VHC vanilla as ordered and then document the percentage of

the nutritional supplement the Resident consumed but there was no documentation in February 2025 or March 2025 to indicate the Resident had been offered the Boost VHC vanilla. The Dietician said she was unsure if she had followed up regarding why there was no documentation on the days Resident #163 should have been administered the Boost VHC vanilla.

During an interview 3/20/25 at 2:13 P.M., the Dietician provided the surveyor with an email from UM #2 indicating Resident #163 did not like the Boost VHC vanilla. The Dietician said nursing staff at that time should have changed the order to provide Resident #163 with Boost Breeze which the Resident preferred and this was not done.

During an interview on 3/24/25 at 10:49 A.M., UM #2 said all Nurses working on the unit should review as needed (PRN) orders every shift. UM #2 said the order for Boost VHC vanilla was a PRN order for when Resident #163 ate less than 50% of his/her meal. UM #2 said she was unsure why the order for the Boost VHC vanilla was never implemented as ordered. UM #2 also said staff were aware Resident #163 preferred Boost Breeze over Boost VHC vanilla and nursing staff should have had the order changed to Boost Breeze and this was not done.

50138

2. Resident #89 was admitted to the facility in October 2024 with diagnoses including End Stage Renal Disease (ESRD), Diastolic Congestive Heart Failure and Type Two Diabetes Mellitus with Diabetic Chronic Kidney Disease.

Review of Resident #89's March 2025 Physician's orders indicated:

-Fluid restriction 1200 ml (milliliter) a day, effective 10/22/24.

-May not omit diet restriction on special occasions, effective 10/18/24.

-Hemodialysis via shunt Tuesdays, Thursdays and Saturdays.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 #89's Comprehensive Person-Centered Care Plans indicated:

Level of Harm - Minimal harm or <Hydration, effective 10/31/24: Problem = Resident #89 had a potential alteration in hydration status related potential for actual harm to fluid restriction, kidney disease and diuretic use with interventions that included - Establish fluid plan including meals, med pass and nourishments. Residents Affected - Some <End Stage Renal Disease, effective 10/21/24: Problem: Resident #89 has required Hemodialysis with interventions including a fluid restriction as ordered with intake monitoring.

Review of Resident #89's Medication Administration Records (MAR) from January 2025, February 2025 and March 2025 indicated the following;

Fluid Restriction 1200 ml/day:

-Day shift (7:00 A.M.-3:00 P.M.) Dietary: Breakfast 240 ml, Lunch 240 ml. Nursing: Day = 600 ml, effective 10/22/24.

-Evening Shift (3:00 P.M.-11:00 P.M.) Dietary: Dinner 120 ml. Nursing Evening = 480 ml, effective 10/22/24.

-Night Shift (11:00 P.M.-7:00 A.M.) Nursing NOC (night) =120 ml, effective 10/22/24.

On 3/20/25 at 11:40 A.M., the surveyor and UM #3 reviewed Resident #89's MAR's which indicated:

-January 2025 MAR: total documented daily intake exceeded the 1200 ml limit for 29 out of 31 days, and was not totaled accurately.

-February 2025 MAR: total documented daily intake exceeded the 1200 ml limit for 26 out of 28 days, total was inaccurate.

-March 2025 MAR: total documented daily intake exceeded the 1200 ml for 16 out of 19 days, total was inaccurate.

During an interview at the time, UM #3 said that Resident #89's fluid intake was not totaled accurately during January 2025, February 2025, and March 2025, but should have been because too much fluid could be dangerous to a hemodialysis resident. UM #3 said that Resident #89's fluid restriction breakdowns by shift

on the Resident's MAR was entered incorrectly to equal 1800 ml and should have been 1200 ml.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 During an interview on 3/20/25 at 8:07 A.M., the Director of Nursing (DON) said that Resident #89 was ordered for a 1200 ml fluid restriction by the Physician. The DON said that the shift-to-shift breakdown on the Level of Harm - Minimal harm or Resident's MAR for fluids allowed under the current fluid restriction order exceeded the 1200 ml fluid potential for actual harm restriction and totaled 1800 ml. The DON said that the Registered Dietitian (RD) made the recommendation for fluid restriction breakdown via email to the DON for dietary and nursing to share. The DON said that the Residents Affected - Some Unit Manager (UM) is then responsible to transcribe the fluid restriction breakdown recommendation to the Resident's MAR so that each shift would know how much fluid should be provided per shift. The DON said that the fluid restriction recommendations were transcribed incorrectly by the UM and the Resident was therefore allotted for 1800 ml of fluids a day, not the ordered 1200 ml/daily. The DON said that daily intakes should be totaled by the night shift (11:00 P.M.-7:00 A.M.) Nurse but they were not. The DON said that accurate totaling of fluid intake was important for Resident #89 so that a fluid imbalance could be identified.

The DON said when a Residents' fluid balance was over the prescribed fluid restriction the UM should notify

the Residents' Provider because having too much fluid intake could result in fluid volume overload and cause cardiopulmonary distress.

During an interview on 3/24/25 at 11:55 A.M., the RD said that she first identified that fluid intake documentation for Resident #89 was a concern last week during survey when questions were raised by the survey team. The RD said that fluid restrictions were a part of a therapeutic diet order and should be followed. The RD said that the fluid intake for Resident #89 was a concern because the fluid restriction had been exceeded and not totaled every day. The RD said that if a Resident exceeds the daily fluid restriction it would be a concern because excess fluids could be more taxing on the resident's system and affect the level of dialysis required as an outpatient. The RD said that if a Resident was regularly going over the fluid restriction the facility nurses should provide notification to the RD and Physician. The RD said she had not been notified by the nursing staff relative to Resident #89 exceeding the fluid restriction regularly but should have been.

47901

3. Resident #125 was admitted to the facility in January 2025 with diagnoses including End Stage Renal Disease (ESRD), Congestive Heart Failure (CHF), Diabetes Mellitus (DM), Hypertension (HTN), and Respiratory Failure with Hypoxia.

Review of Resident #125's Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of total possible 15.

Review of Resident #125's March 2025 Physician orders, dated 1/28/25, indicated:

-Fluid Restriction 1200 milliliters (ml) per day

>Dietary Day Shift Breakfast - 240 ml

>Lunch - 240 ml

>Nursing Day - 600 ml

-Add meal intake to total shift

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 #125's Dietician Progress Note dated 1/30/25, indicated:

Level of Harm - Minimal harm or -Resident back from stay in hospital due to CHF and SOB (Shortness of Breath). potential for actual harm -Before Dialysis weight in hospital was reported as 186.5 pounds. Residents Affected - Some -After dialysis weight was reported as 166.5 pounds.

-Indicates the Resident was retaining more fluids

-Current diet order HCC/renal/mech soft/thin

-1200 ml fluid restriction.

-Continue fluid restriction 1200 ml due to recent hospitalization .

On 3/20/25 at 8:43 A.M., the surveyor and Unit Manager (UM) #5 reviewed Resident #125's Physician order and Intake and Output (I&O) documentation and the following were identified:

-Physician order for fluid intake did not include supper, evening shift, and night shift.

-I&O for January 2025 was not documented for nursing on the MAR.

-I&O's for February 2025 were over the 1200 ml every day

-I&O's for 3/1/25 - 3/19/25, were over the 1200 ml fluid restriction limit.

During an interview at the time, UM #5 said Resident #125's fluid restrictions had not been reviewed by facility staff, and they should have been reviewed. UM #5 further said the Physician's order was inaccurate.

During an interview on 3/20/25 at 10:16 A.M., Clinical Nurse Support (CNS) #3 said the Physician order was inaccurate, the facility staff had not reviewed the I&O, and they should have.

37400

4. Resident #40 was admitted to the facility in August 2020 with diagnoses including End Stage Renal Disease (ESRD) and Pulmonary Edema.

Review of the MDS Assessment, dated 12/25/24, indicated Resident #40:

-was cognitively intact as evidenced by a BIMS score of 15 out of 15

-received a therapeutically altered diet

-was on dialysis

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 the Renal Dialysis Care Plan, initiated 10/20/20 and revised 1/25/25, indicated Resident #40 had a need for hemodialysis and included the following interventions also initiated 10/20/20: Level of Harm - Minimal harm or potential for actual harm -monitor for signs and symptoms of fluid overload (shortness of breath, increased fatigue, significant weight gain, edema). Residents Affected - Some -Notify Medical Doctor/Nurse Practitioner of significant changes as needed.

-fluid restriction as ordered with intake monitoring (see nutritional care plan)

Review of the Nutritional Care Plan, initiated 8/19/20 and revised 3/18/25, indicated Resident #40 presented at nutritional risk related to kidney and endocrine dysfunction and end stage renal disease requiring hemodialysis and poor diet compliance, and included the following interventions:

-fluid restriction as ordered, dated 3/18/25

-document intake regarding percent (%) of solids and fluids consumed, dated 3/18/25

-educate resident and family on dietary restrictions, dated 3/18/25

Review of the Certified Nurses Aide (CNA) Care Card indicated Resident #40 was on a 1500 ml Fluid Restriction.

Review of the March 2025 Physician's Orders included the following orders, initiated 1/23/25:

-Day Fluid Restriction 1500 ml, Day shift (7:00 A.M. to 3:00 P.M.):

>Dietary: breakfast =240 ml

>Dietary: lunch = 240 ml

>Nursing Day = 300 ml

>add meal intake to total shift intake

-Eve [sic] Fluid Restriction 1500 ml, Evening shift (3:00 P.M. to 11:00 P.M.):

>Dietary: dinner = 240 ml

>Nursing: Eve = 300 ml

>add meal intake to total shift intake

-Noc [sic] Fluid Restriction 1500 ml, Noc shift (11:00 P.M. to 7:00 A.M.)

>Nursing Noc = 180 ml

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 the January 2025 to March 2025 Medication Administration Records (MARs) indicated the total fluid intake amounts recorded on each shift and the total 24- hour total amounts recorded with the following Level of Harm - Minimal harm or results: potential for actual harm January 2025 Residents Affected - Some -24-hour total = 0 mls was documented twice 1/23/25, 1/31/25

-1500 ml restriction was exceeded on 1/23/25, 1/25/25

-24-hour total documented that was different from intake totals on 1/24/25, 1/25/25,1/26/25,1/27/25, 1/29/25, 1/31/25

February 2025

-24-hour total = 0 mls was documented 2/2/25, 2/5/25, 2/7/25, 2/8/25, 2/14/25, 2/17/25, 2/19/25, 2/26/25

-24-hour total documented that was different from intake totals on 2/1/25 - 2/28/25

March 2025

-24-hour total = 0 mls was documented four times on 3/2/25, 3/15/25, 3/21/25, 3/22/25

-1500 ml restriction was exceeded on 3/4/25

-24-hour total documented that was different from intake totals on 3/1/25 - 3/22/25

Review of the CNA Meal Intake by Day Report from January through March 2025 indicated Resident #40 consumed more than the allotted 240 mls with each meal on the following:

January 2025

-Breakfast: 1/25/25 - 1/30/25

-Lunch: 1/24/25

-Dinner: 1/23/25, 1/31/25

-No intake documentation for breakfast and lunch - 1/23/25, 1/31/25

February 2025

-Breakfast: 2/1/25, 2/3/25 - 2/6/25, 2/8/25 - 2/11/25, 2/14/25 - 2/16/25, 2/18/25, 2/20/25 - 2/21/25, 2/23/25 - 2/25/25, 2/27/25 - 2/28/25

-Lunch: 2/2/25, 2/17/25

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 -Dinner: 2/7/25, 2/12/25

Level of Harm - Minimal harm or March 2025 potential for actual harm -Breakfast: 3/1/25 - 3/10/25, 3/13/25 - 3/15/25 - 3/20/25, 3/22/25 - 3/23/25 Residents Affected - Some -Lunch: 3/1/25 - 3/5/25, 3/8/25 - 3/10/25, 3/13/25, 3/15/25, 3/17/25 - 3/18/25, 3/20/25 -3/23/25

-Dinner: 3/1/25, 3/3/25, 3/5/25, 3/8/25 - 3/10/25, 3/11/25, 3/15/25 - 3/23/25

On 3/20/25 at 3:50 P.M., the surveyor observed Resident #40 seated upright in bed and multiple closed individual cups containing apple juice were observed on the Resident's over bed table along with a large reusable covered cup with a straw which were within the Resident's reach. Two open containers of ice cream were observed on the Resident's bed and the surveyor observed him/her eating one. During an interview at

the time, Resident #40 said he/she was on a fluid restriction, was unsure how much the fluid restriction was for, but was allowed to have the fluid contained in the large reusable cup daily. Resident #40 said he/she kept the cups of apple juice on his/her overbed table to use when he/she needed to take a medication to lower his/her potassium level because he/she liked to mix the medication in the apple juice. Resident #40 said he/she did not usually consume all of the drinks provided on his/her meal trays but usually consumed

the coffee.

During an interview on 3/24/25 at 10:13 A.M., CNA # 1 said Resident #40 was on a fluid restriction but he was not sure how much he/she was allowed to have with meals. CNA #1 said Resident #40 usually received

an eight ounce (oz) carton of milk and a container of juice (4 oz) with meals. CNA #1 said that he documents

the amount the Resident consumes of the food and fluids in the CNA documentation and would report to the Nurse if the Resident didn't eat/drink because that would be a change for him/her.

On 3/24/25 at 12:01 P.M., the surveyor requested copies of the Resident #40's meal tickets from the Food Service Supervisor. The meal tickets included the following:

-Fluid Rest: (sic) 1500 ml D: 720, which was located on each meal ticket.

During an interview at the time, the Food Service Supervisor said Resident #40 was on 1500 ml Fluid Restriction. When the surveyor asked about the 720 indicated on each meal ticket, the Food Service Supervisor said she was not sure, but thought it may be the fluid amount allowed for that meal. The Food Service Supervisor said when she was notified that a Resident was on a fluid restriction, nursing would notify

the kitchen of the amounts allowed from meals and then she or the Dietitian would meet with the Resident to

review what fluids were requested with meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 On 3/24/25 at 12:13 P.M., the surveyor and the Dietitian reviewed Resident #40's meal tickets. During an

interview at the time, the Dietitian said the D: 720 indicated the total amount of fluids allowed from dietary for Level of Harm - Minimal harm or the day, not for the meal. The Dietitian said there was a breakdown of fluid amounts that were to be provided potential for actual harm with each meal from dietary. The Dietitian said that if the Resident was routinely going over his/her fluid restriction amount, she would expect the facility staff to notify her so she could follow-up with the Resident. Residents Affected - Some The Dietitian said if extra fluids were provided to the Resident, it could be taxing on him/her because he/she goes to dialysis, and it would be more fluid that would need to be removed during the dialysis process. The Dietitian said she did not routinely review the 24-hour fluid intakes documented by nursing and after reviewing the 24-hour fluid amounts for Resident #40, she further said that there needed to be more education with the nursing staff about fluid restrictions. The Dietitian reviewed the printout of Resident #40's meal tickets and said some of the information on the Resident's tickets were not accurate.

During an interview on 3/24/25 at 3:10 P.M., Nurse #5, who regularly worked the 11:00 P.M. to 7:00 A.M. shift, said fluid restriction amounts for residents were broken up by the three nursing shifts. Nurse #5 said

she would document the amount she provided to the resident on her shift and would then total the amounts provided on the other shifts and document total fluid amount on the 24-hour totals. Nurse #5 said sometimes

the fluid amounts were not documented on previous shifts, so she would mark not applicable and notify the UM. Nurse #5 said there were some residents who were not good about following their fluid restrictions, and if they went over their fluid amounts allotted for the day, she would provide education to them and document

this in the resident's clincal record. Nurse #5 said she also communicated with the CNAs about how much fluid they provided to the resident and this would be documented on the fluid amounts for that shift.

During an interview on 3/24/25 at 4:27 P.M., UM #1 said for residents on fluid restriction, the Nurses should be documenting the total fluid intake amounts consumed during their shift which included fluids taken during meals, snacks and what nursing provided. UM #1 said the 11:00 P.M. to 7:00 A.M. shift should total these shift amounts and complete the 24-hour fluid intake totals. UM #1 said the resident's fluid intake amounts should be reviewed every couple of days for trends, and if the resident was over the fluid restriction amount,

the Physician and the Dietitian would be notified. UM #1 said the CNAs should know when a resident was on

a fluid restriction and there should be communication between the CNAs and the Nurses relative to the fluid amounts the resident consumed during that shift.

During an interview on 3/25/25 at 10:46 A.M., Dietary Staff #3 said items like coffee, tea, juices, ice cream, sauces, gravies and soup count as fluids. Dietary Staff #3 said when a resident is on a fluid restriction, the dietary staff would follow what was listed on the resident's meal tickets which indicate what should be put on

the meal trays.

During a follow-up interview on 3/25/25 at 10:48 A.M., the Food Service Supervisor said she was working with the Dietitian to review the resident meal tickets relative to fluid restrictions. The Food Service Supervisor said any liquid drinks, soups, ice cream and Jello would count as liquids. The Food Service Supervisor said

she didn't count sauces, gravies and creamers as fluids but she probably should. The Food Service Supervisor said she reviewed what the D: 720 meant on Resident #40's meal tickets and was told that it was total fluid amount allowed from dietary for the day, not for each meal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 37400 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one Resident (#40) received Residents Affected - Few dialysis care in accordance with professional standards of practice for three applicable residents receiving dialysis, out of a total sample of 36 residents.

Specifically, the facility failed to ensure nursing assessments, including assessment of the dialysis access site, vital signs and blood sugar levels, were performed when Resident #40 returned from dialysis.

Findings include:

Review of the facility policy titled Coordination of Care of Dialysis Residents, revised 11/19/18, indicated the nursing facility was responsible for the overall quality of care and services the resident receives and provides

the services, consistent with professional standard of practices, to residents receiving dialysis as outlined by their comprehensive person-centered plan of care.

The policy also included the following:

-a comprehensive person-centered plan of care is developed and implemented based on comprehensive assessment in collaboration with the Dialysis Center, in accordance with professional standards of practice.

-the plan of care will be evaluated an revised as indicated based on resident's response to interventions.

-care plan will include:

>monitoring of vital signs .

Resident #40 was admitted to the facility in August 2020 with diagnoses including End Stage Renal Disease (ESRD) and Diabetes.

Review of the Renal Dialysis Care Plan initiated 10/20/20, indicated Resident #40 received hemodialysis on Mondays, Wednesdays and Fridays for End Stage Renal Disease.

The plan of care included the following interventions:

-monitor for complications of dialysis, hypotension, anemia, muscle cramps, and blood loss as indicated.

Review of the Minimum Data Set (MDS) Assessment, dated 12/25/24, indicated Resident #40:

-was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 -was on dialysis

Level of Harm - Minimal harm or Review of the March 2025 Physician's orders included the following: potential for actual harm -Dialysis: Mondays, Wednesdays and Fridays, initiated 2/6/25 Residents Affected - Few

Review of the Dialysis Communication Record form, utilized by the facility, indicated three sections labeled as follows:

*Section A: to be completed by the facility, which included the following information to be obtained prior to transfer to the dialysis clinic:

-location, type and assessment of the dialysis access site,

-vitals time,

-temperature,

-heart rate,

-respiratory rate,

-oxygen saturation level,

-blood pressure,

-blood glucose level.

*Section B: to be completed by the dialysis center .

*Section C: to be completed by the facility on Resident return to facility, which included the following information:

-assessment of the dialysis access site

-vitals time,

-temperature,

-heart rate,

-respiratory rate,

-oxygen saturation level,

-blood pressure,

-blood glucose level

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 Review of the Dialysis Communication Forms, dated 1/1/25 through 3/24/25, failed to indicate documented evidence that a nursing assessment was completed which included an assessment of the Resident's access Level of Harm - Minimal harm or site and vitals and blood sugar levels upon return from dialysis treatments, for 26 out of 34 treatments. potential for actual harm

During an interview on 3/20/25 at 10:04 A.M., Resident #40 said he/she received dialysis yesterday Residents Affected - Few (Wednesday 3/19/25) and was tired today. Resident #40 said he/she has been on dialysis for about five years and it takes a lot out of him/her. Resident #40 said he/she leaves the facility early in the morning and returns to the facility around lunch time.

During a follow-up interview on 3/24/25 at 3:44 P.M., Resident #40 said he/she had dialysis treatment today and was very tired. Resident #40 said he/she has a dialysis communication book that was given to the Nurses when he/she returned to the facility from dialysis treatments. Resident #40 said he/she has a fistula and has had no issues with it. Resident #40 said he/she has been having increased episodes of nausea and that he/she took a medication for relief.

During an inteview on 3/24/25 at 4:19 P.M., Nurse #11, who worked Per Diem at the facility, said she obtained the Resident's vitals today upon his/her return from dialysis. Nurse #11 said she documented the Resident's vitals in the dialysis communication book and they were stable. Nurse #11 further said the Resident requested medication which was administered for nausea and pain upon return from dialysis.

During an interview on 3/24/25 at 4:27 P.M., Unit Manager (UM) #1 said the expectation was for nursing to assess Resident #40 when he/she returned from dialysis and part of that assessment would include obtaining vitals signs upon return. UM #1 said it was important to check the Resident's dialysis site for bleeding and check his/her vitals to assess tolerance to treatment. UM #1 said she reviewed the Resident's clinical record and the Dialysis Communication Forms and noticed that the required information had not been consistently obtained by the nursing staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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** 42741 potential for actual harm Based on interview, and record review, the facility failed to ensure that triggers relative to a past trauma were Residents Affected - Few identified to create an individualized trauma care plan for one Resident (#199) out of a total sample of 36 residents.

Specifically, for Resident #199, the facility failed to ensure that an individualized care plan addressed Resident #199's triggers so they could be reduced in his/her environment.

Findings include:

Review of the facility policy titled Trauma Informed Care, revised 6/17/24, indicated the following:

-Social service department will develop a person-centered trauma-informed care plan that addresses the assessed emotional and psychosocial needs of the resident.

-Interdisciplinary team (IDT) to provide ongoing assessment, evaluation, and revision of care plan.

Resident #199 was admitted to the facility in June 2024 with diagnoses including Cerebral Infarction (stroke) with left sided hemiplegia and hemiparesis and Major Depressive Disorder.

Review of the most recent Minimum Data Set (MDS) Assessment, dated 12/4/24 indicated Resident #199:

-had clear speech

-was usually able to make his/herself understood

-usually able to understand others

During an interview on 3/18/25 at 4:50 P.M., Resident #199 said he/she was having a difficult time adjusting to his/her room since his/her most recent room change. Resident #199 said he/she had a history of trauma and doors slamming, loud noises he/she could not see the source of, dark spaces, and inability to lock his/her door were things that increased his/her anxiety. Resident #199 said pulling the curtain closed between him/her and the roommates' side of the room, having the television or radio playing at night, keeping the door closed (when in the community he/she closed and locked all doors at night) were coping mechanisms to help with periods of increased anxiety. Resident #199 said it was very difficult at night because he/she was not able to close the door to his/her room because of his/her roommate and was unable to have the television on at night to help reduce the sound of loud noises from the hallway.

Review of Resident #199's Trauma Informed Care assessment dated [DATE REDACTED], indicated:

-Have you ever had an experience so upsetting that you think it changed you emotionally, spiritually, physically or behaviorally? -Yes

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 -Do you think any of these things bother you now? -Yes

Level of Harm - Minimal harm or -Sexual Assault? -Experienced potential for actual harm -Avoided Activities or situation because they reminded you? -Most of the time Residents Affected - Few Further review of the Trauma Informed Care Assessment failed to indicate documentation on what interventions where beneficial for the Resident or what coping skills the Resident utilized relative to his/her past history of trauma.

Review of the Resident #199's Trauma Care Plan, dated 7/3/24, indicated the following:

-Identify triggers for anxiety, psychosocial decline.

Further review of the Trauma Care Plan failed to indicate Resident #199's:

-trauma triggers

-coping mechanisms

During an interview on 3/20/25 at 8:33 A.M., Social Worker (SW) #1 said she was aware Resident #199 had

a history of trauma because it was identified on the Trauma Informed Care Assessment completed on 6/20/24 and because the Resident's Guardian had expressed that Resident #199 often became more anxious when he/she heard other people crying out. SW #1 said she had not spoken with Resident #199 about specific triggers or coping strategies he/she used during periods of increased anxiety. SW #1 said a person-centered care plan should be created for any resident with a history of trauma. SW #1 further said the staff should identify what a resident's trauma triggers were and the best interventions/coping mechanisms that the resident could use, or that the staff could use to help the resident through any changes in their psychosocial well-being. The surveyor and SW #1 reviewed Resident #199's Trauma Care Plan and SW #1 said Resident #199's Care Plan was not individualized. SW #1 said there were no specific triggers for staff to watch out for and no specific coping mechanisms that the Resident utilized to reduce his/her anxiety included

in the Care Plan. SW #1 said the Resident's Trauma Care Plan should have been updated to include triggers and person-centered interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50563 potential for actual harm Based on observation, interview, and record review, the facility failed to provide appropriate medical care Residents Affected - Few and supervision for one Resident (#224) out of a total sample of 36 Residents.

Specifically, for Resident #224, the facility failed to ensure that the Provider was aware of the Resident's weight loss and oversaw his/her nutritional status.

Findings include:

Resident #224 was admitted to the facility in February 2025 with diagnoses including Anoxic Brain Damage, posterior reversible Encephalopathy, Aphasia and Gastrostomy Status.

Review of Resident #224's Minimum Data Set (MDS) assessment dated [DATE REDACTED]. indicated:

-based on staff assessment the Resident had some difficulty with daily decision making in new situations only.

-the Resident received 25 - 50% of his/her caloric intake from Tube Feeding.

Review of Resident #224's weights indicated the following:

-2/21/25: 196.6 pounds (lbs)

-3/4/25: 189 lbs.

-3/5/25: 186.6 lbs. (a 5% loss in less than 30 days)

Review of Resident #224's medical record failed to indicate any evidence the Provider was aware of the Resident's weight loss and was supervising immediate care for nutritional needs.

During an interview on 3/25/25 at 9:52 A.M., the surveyor and Unit Manager (UM) #1 reviewed Resident #224's weights. UM #1 said that the Provider should be made aware of the weight loss and would review the record.

During a follow-up interview on 3/25/25 at 10:24 A.M., UM #1 said that 3/5/25 was a re-weight and that was not accepted. UM #1 further said a second re-weight was completed again on 3/13/25, but waiting eight days to complete a re-weight was not an acceptable timeframe as the weight would have the potential to have changed in that time. UM#1 said that if there is a significant weight loss of 5% or more, the Provider should have been notified to oversee the Resident's care but she could find no evidence in the medical record that

the Provider was notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 47901

Residents Affected - Few Based on interview, and record review, the facility failed to ensure that appropriate competencies related to medication administration was completed for one Licensed Nurse (Nurse #9) out of 5 staff records reviewed.

Specifically, the facility failed to provide documentation that Nurse #9 had completed the appropriate nursing competencies for medication administration and controlled substances (a drug or chemical that the government regulates for its manufacture, possession and use, that are classified into schedules based on their potential for abuse) documentation.

Findings include:

Review of the facility policy titled Management of Controlled Substance in Skilled Nursing Facilities, revised 10/19/2022, indicated:

-It is the responsibility of staff to administer or otherwise manage medications to safeguard controlled substances in a manner consistent with Federal and State law, and organizational policy.

Purpose:

-To provide for proper ordering, storage, disposal, and security of controlled substances.

-To minimize the opportunity for abuse or diversion of controlled substances.

-To promote occupational and patient safety.

-Medication information is logged into the Controlled Substances Register as follows:

>One controlled substance per patient page.

>Each new patient page shall include:

>Patient's name.

>Prescriber's name.

>Drug name and strength.

>Directions for use.

>Prescription number and date.

Review of the Facility Assessment, revised on 7/26/24, indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 -It is the policy of the facility to assure all staff are provided education and competency training based on the needs of the resident population that is consistent within their expected role. Level of Harm - Minimal harm or potential for actual harm -Mandatory education and training is required that outlines clinical capabilities and based on resident population. Residents Affected - Few

On 3/25/25 at 9:35 A.M., the surveyor reviewed the controlled substance register on the Unit Two, side two medication cart. The surveyor observed that the controlled substance register had no prescription numbers documented and no date of receipt of the controlled substances. Further review of the controlled substance register indicated Nurse #9 had signed as the Nurse on duty, and had received count of the controlled substances that were in her possession.

During an interview on 3/25/25 at 9:40 A.M., Nurse #9 said there was no need to document the prescription numbers in the controlled substance register. Nurse #9 also said there was no need to document the date

the controlled substances had been received from the pharmacy.

During an interview on 3/25/25 at 11:02 A.M., the Staff Development Coordination (SDC) said Nurse #9 was new to the facility and was hired on 3/2/25. The SDC said Nurse #9 was in training and did not complete the competency for medication administration and/or competency for the documentation of controlled substances.

During a follow-up interview on 3/25/25 at 1:15 P.M., the SDC said Nurse #9 should not have been in receipt of the controlled substances. The SDC further said Nurse #9 should not have been on the medication cart by herself until the nursing competency for medication administration and the competency for controlled substances had been completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0732 Post nurse staffing information every day.

Level of Harm - Potential for 42741 minimal harm Based on observation, interview, and record review, the facility failed to post on a daily basis required nurse Residents Affected - Some staffing information that included the actual hours worked by licensed and unlicensed nursing staff and the daily census.

Findings include:

The surveyor observed that nurse staffing information was posted in the entry of the facility on the following days:

-3/18/25

-3/19/25

-3/23/25

-3/24/25

Review of the nurse staffing information posted indicated the name of the facility, the date, and the total amount of nursing staff working on each unit for the day and evening shift. The posted nurse staffing information was observed to include (2) 3:00 P.M. - 11:00 P.M. (evening) shift staffing and failed to indicate any 11:00 P.M. - 7:00 A.M. (night) shift staffing.

Further review of the nurse staffing information postings failed to indicate the actual hours worked by licensed and unlicensed nursing staff and the daily resident census.

During an interview on 3/24/25 at 7:29 A.M., the facility Scheduler said she was the one who posted the daily staffing information and she was unaware of any additional information that was needed on the posted nursing staff information. The Scheduler further said at this time she was not tracking the total hours worked each day by nursing staff.

During an interview on 3/24/25 at 3:53 P.M., the Scheduler said the actual working hours were not posted on

the daily nurse staffing information and the posting also did not include the daily census. The surveyor and

the Scheduler reviewed the daily nurse staffing postings from 3/18/25 through 3/24/25 and the Scheduler said none of the daily postings contained the necessary information pertaining to the actual hours worked by nursing staff or the daily resident census. The Scheduler said she would work with the Director of Nursing (DON) to update the nurse staffing posting to contain all the necessary information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 47901

Residents Affected - Few Based on record review, and interview, the facility failed to maintain accurate documentation of controlled substance (a drug or chemical that the government regulates for its manufacture, possession and use, that are classified into schedules based on their potential for abuse) for two units (Unit 2, side one and Unit 2, side two) out of five units reviewed.

Specifically, the facility failed to maintain accurate documentation in the controlled substance register (Narcotic Book Documentation).

Findings include:

Review of the facility policy titled Management of Controlled Substance in Skilled Nursing Facilities, revised 10/19/22, indicated:

-It is the responsibility of staff to administer or otherwise manage medications to safeguard controlled substances in a manner consistent with Federal and State law, and organizational policy.

Purpose:

-To provide for proper ordering, storage, disposal and security of controlled substances.

-To minimize the opportunity for abuse or diversion of controlled substances.

-To promote occupational and patient safety.

-Medication information is logged into the Controlled Substances Register as follows:

>One controlled substance per patient page.

>Each new patient page shall include:

>Patient's name.

>Prescriber's name.

>Drug name and strength.

>Directions for use.

>Prescription number and date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0755 On 3/25/25 at 9:20 A.M., the surveyor and Unit Manager (UM) #5 reviewed the controlled substance register

on Unit 2, side one. The surveyor observed that the controlled substance register did not include Level of Harm - Minimal harm or documentation of prescription numbers for the controlled substance medications and no dates indicating potential for actual harm receipt of the controlled substance medications. During an interview at the time, UM #5 said the prescription numbers of the controlled substances should have been documented in the controlled substance register but Residents Affected - Few there were not.

On 3/25/25 at 9:35 A.M., the surveyor reviewed the controlled substance register on the Unit 2, side two medication cart. The surveyor observed that the controlled substance register had no prescription numbers documented and no dates of the receipt of the controlled substance medications.

On 3/25/25 at 9:57 A.M., the surveyor and Nurse #6 reviewed the controlled substance register on Unit 1, side two. Nurse #6 said 48 pages of the controlled substance register did not have documentation for prescription numbers and dates the controlled substances were received from the pharmacy.

On 3/25/24 at 10:06 A.M., the surveyor and Nurse #10 reviewed the controlled substance register on Unit 1, side one. Nurse #10 said 175 pages of the controlled substance register did not have the prescription numbers of the controlled substance medications documented and the dates the controlled substances were received from the pharmacy.

During an interview on 3/25/24 at 10:37 A.M., the Director of Nursing (DON) said the prescription numbers for the controlled substance medications and the dates the controlled substances were received should be documented in the controlled substance register, but they were not documented. The DON further said it was important to accurately document the prescription numbers and dates the medications were received to minimize the opportunity for abuse or diversion of controlled substances.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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** 50138 potential for actual harm Based on record review, interview, and observation, the facility failed to provide routine dental services for Residents Affected - Few two Residents (#47 and #186) out of a total sample of 36 residents.

Specifically,

1. For Resident #47, the facility staff failed to follow through on a Doctor of Medicine in Dentistry (DMD) recommendation to have the Resident seen by an Oral Surgeon for a tooth extraction resulting in delayed dental care and services.

2. For Resident #186, the facility failed to assist the Resident in making an appointment for recommended dental extractions in a timely manner which resulted in a delay in dental care and increased risk for oral pain and infection.

Findings include:

Review of the facility policy titled Consulting Services Podiatry/Dental/Optometry/Audiology, dated 11/22/16, included but was not limited to the following:

-The facility has a contract with credentialed providers for inhouse services of podiatry, dental, optometry and audiology.

-Facility will arrange appointments as requested by resident/resident representative.

-The facility will arrange transportation as needed, to providers of resident/resident representative's choice.

-Resident/Resident Representative provides written consent to treatment prior to services.

-Appointment is arranged by facility staff.

-Transportation is arranged by facility staff for outside appointments.

-Credentialed consultant documents care, and services provided in medical record.

-Consultant brings forward to a licensed professional any urgent care needs based on their consultation.

1. Resident #47 was admitted to the facility in March 2023 with diagnoses including Dysphagia and Dementia.

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated that Resident # 47 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of a possible total score of 15.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 Review of Resident #47's Medical Record indicated:

Level of Harm - Minimal harm or -has a legally appointed Guardian, effective 9/11/24. potential for actual harm -has a signed consent for Dental services, effective 5/5/23. Residents Affected - Few

Review of Resident #47's Comprehensive Person-Centered Care Plan, initiated 3/26/23, indicated:

-has a problem for oral/dental health due to poor dentition

-interventions including annual oral/dental exams and PRN (as needed) visits for dental issues.

Review of Resident #47's Dental Group Consultant Sheet dated 3/12/24, and signed by the DMD indicated:

-has teeth in poor condition with heavy soft plaque/food debris build up and heavy hard calculus deposits.

-has moderate inflammation/swollen bleeding gums, was at high risk for caries (bone or tooth decay), and has fair periodontal condition.

-Resident requested for tooth #27 to be extracted.

-Action required by the nursing home staff was for referral to an Oral Surgeon for extraction of tooth #27.

During an interview on 3/18/25 at 10:47 A.M., Resident #47 said this tooth was supposed to come out. Resident #47 indicated a tooth on the front of their lower oral cavity. The surveyor observed that the Resident had some broken teeth along the front lower gum line.

During an interview on 3/24/25 at 3:10 P.M., the Quality Improvement Coordinator (QIC ) Nurse #1 said that Resident #47 was recommended to have a referral to an Oral Surgeon for tooth extraction during the 3/12/24 DMD visit, but did not have the referral completed. QIC Nurse #1 said that she was unaware of why the Resident was not sent out to an Oral Surgeon as recommended by the DMD on 3/12/24.

On 3/25/25 at 8:21 A.M., the surveyor and the Director of Nursing (DON) reviewed the Dental Group recommendation for Resident #47 dated 3/12/24, which indicated a recommendation for an Oral Surgeon referral was needed for extraction of tooth #27. During an interview at the time, the DON said that consult referrals should be made by the unit secretary under the direction of the Unit Manager (UM). The DON said that the recommendation from the Dental Group from 3/12/24, was not addressed but should have been addressed within the week of 3/12/24.

During an interview on 3/25/25 at 11:00 A.M., UM #3 said that Resident #47 had not been seen by an Oral Surgeon as recommended by the DMD on 3/21/24. UM #3 said that she was unable to provide evidence that Resident #47's Guardian had been made aware of the need for a referral to an Oral Surgeon.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 During a follow-up interview at 11:32 A.M., UM #3 said that Resident #47's Guardian had not been made aware by the facility of the DMD recommendations from 3/21/24 for an Oral Surgeon referral but was notified Level of Harm - Minimal harm or today by UM #3. potential for actual harm 42761 Residents Affected - Few 2. Resident #186 was admitted to the facility in October 2023 with diagnoses including Obesity and Left Below Knee Amputation (BKA).

Review of Resident #186's Dental Consult, dated 9/27/24, indicated:

-Resident presented for dental evaluation due to a sharp tooth.

-Dentist discussed with the Resident that the sharp tooth had caries (tooth decay or cavities, if left untreated can result in pain and infection).

-Resident had another tooth that was a root tip (furthest end of a tooth root, located below the gumline).

-Resident wanted both of the teeth removed to limit any future discomfort.

-Actions required by nursing staff included referral to MD/OS (Oral Surgeon) for extraction of the two teeth.

Review of Resident #186's Minimum Data Set (MDS) Assessment, dated 3/4/25, indicated:

-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out 15 total possible points.

-had no mouth or facial pain.

-had no discomfort or difficulty chewing.

Review of Resident #186's clinical record failed to indicate evidence the Resident had been referred to the Oral Surgeon (OS) for his/her teeth to be extracted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 On 3/18/25 at 11:26 A.M., the surveyor observed Resident #186 positioned in bed in his/her room. The Resident was talking to his/her roommate and the surveyor observed that the Resident had natural teeth. Level of Harm - Minimal harm or During an interview at the time, Resident #186 said he/she had been seen by a Dentist months prior and had potential for actual harm two teeth that needed to be extracted. When Resident #186 spoke to the surveyor, the surveyor observed that the Resident had some natural teeth missing. Resident #186 said that due to his/her physical condition, Residents Affected - Few he/she was not able to tolerate sitting up for lengthy periods of time and that the chair he/she sat in could not be accommodated by the Cabulance [sic] for transport to an OS office. Resident #186 said he/she would need to be transported via stretcher and that a stretcher would not fit in a regular dental treatment room. Resident #186 said facility staff were supposed to assist him/her to locate a dental facility that could accommodate a stretcher and that he/she had not heard anything back from facility staff yet. Resident #186 said that the two teeth needing extracted were not bothering him/her at the time, but he/she had a dental infection in the past from a broken tooth and was afraid that he/she would develop another infection.

During an interview on 3/19/25 at 3:45 P.M., Unit Manager (UM) #3 said Resident #186 had not been able to tolerate sitting up in a chair so he/she was not able to go out to see an OS. UM #3 said if the Resident did go to get his/her teeth extracted, he/she would have to go via stretcher. UM #3 said an option for transporting

the Resident via stretcher had not been explored.

During an interview on 3/20/25 at 10:15 A.M., UM #3 said she spoke with Resident #186 and that Resident #186 said if the facility could locate a dental facility that could accommodate a stretcher, he/she would like to go and have his/her teeth extracted.

During an interview on 3/20/25 at 11:58 A.M., Resident #186 said when the Dentist recommended the two tooth extractions, the Resident knew sitting up out of bed in a chair for the procedure was not an option for him/her. Resident #186 said he/she had not asked facility staff whether they had located a dental facility to accommodate him/her by stretcher. Resident #186 said facility staff told him/her they would work on locating

a dental facility that could accommodate a stretcher and get back to him/her, so he/she was waiting. Resident #186 said the Unit One [NAME] Clerk had alerted him/her about 30 minutes earlier that the facility located a dental facility that would accommodate the Resident via stretcher and that his/her extractions would be scheduled for May 2025.

During an interview on 3/20/25 at 1:46 P.M., the Unit One [NAME] Clerk said she had called local dental facilities in September 2024 for Resident #186 when the Resident was recommended to have tooth extractions. The Unit One [NAME] Clerk said no local dental facilities were able to accommodate a stretcher at that time. The Unit One [NAME] Clerk said she alerted the Resident in September 2024 that she could not locate a dental facility to accommodate a stretcher, and the Resident said, okay. The Unit One [NAME] Clerk said she had not contacted any other dental facilities for Resident #186 since September 2024 until the surveyor's inquiry. The Unit One [NAME] Clerk said she obtained the name of a dental facility that could accommodate residents on stretchers from one of the other [NAME] Clerks in the facility on 3/19/25. The Unit One [NAME] Clerk further said she contacted that dental facility and that the dental facility would accommodate Resident #186 to have his/her teeth extracted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 During an interview on 3/20/25 at 2:30 P.M., the Director of Nursing (DON) said he knew the facility contacted a local dental facility and the local hospital's emergency department in September 2024 to inquire Level of Harm - Minimal harm or whether either facility could accommodate Resident #186 via stretcher for dental extractions. The DON said potential for actual harm the local dental office could not accommodate a stretcher and the local hospital's emergency department would not allow a Dental Provider to come in and perform the extractions. The DON said he was not aware Residents Affected - Few of any other dental facilities that had been contacted until 3/19/25, following the surveyor's inquiry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 42761 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure each resident received food Residents Affected - Few and drink that was palatable and served at an appetizing temperature on two (Unit One and Unit Four) out of four units, where test trays were conducted.

Specifically, the facility failed to ensure:

1. Pureed (food prepared as a smooth, pudding-like texture) asparagus was served consistent with pureed texture and at an appetizing temperature for Residents requiring pureed food on Unit One.

2. For Unit Four, the facility failed to serve palatable food at an appetizing temperature.

Findings include:

Review of the facility's Standard Guidance for Food and Liquid Textures for Individuals Requiring Modified Texture Diets, undated, indicated the following:

-A pureed diet is food with a very smooth consistency or foods that have been well processed in a food processor or blender to a very smooth consistency or texture.

-No solid pieces or parts can be noticed in the food.

-Pureed food has no lumps and feels very soft and smooth in the mouth.

During an interview on 3/18/25 at 8:25 A.M., Resident #82 said that the food was awful and tasted bad.

During an interview on 3/18/25 at 11:34 A.M., Resident #138 said the food at the facility was always served cold.

During an interview on 3/18/25 at 9:05 A.M., Resident #105 said the food was like slop.

During an interview on 3/18/25 at 9:55 A.M., Resident #52 said the food at the facility was not good and was always served late.

During an interview on 3/18/25 at 10:20 A.M., Resident #209 said the food at the facility was horrible and the food was served cold.

During an interview on 3/18/25 at 11:41 A.M., Resident #59 said the food at the facility was not good. Resident #59 further said the food had a bad taste and was served cold.

During an interview on 3/18/25 at 11:55 A.M., Resident #186 said the food at the facility was terrible.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 During an interview on 3/18/25 at 2:02 P.M., Resident #133 said the food at the facility was not good.

Level of Harm - Minimal harm or At this time, the surveyor observed a lunch meal tray on the Resident's over-bed table with all meal items potential for actual harm intact as no food was consumed by the Resident.

Residents Affected - Few 1. On 3/19/25 at 12:47 P.M., the surveyor conducted a lunch meal test tray on Unit One as follows:

-The meal tray consisted of pureed food items and thin texture liquids (mashed potato with gravy, creamed chicken with gravy, asparagus, chocolate cake, coffee, and milk) .

-All food items were warm, palatable, and of expected smooth texture with the exception of the pureed asparagus.

-The pureed asparagus was 98 degrees Fahrenheit (F), cool in the mouth, and contained thin, flat, tough pieces of asparagus that were not smooth in texture.

-The pieces of asparagus that were not prepared to be smooth stuck to the surveyor's tongue while eating.

During an interview on 3/19/25 at 12:47 P.M., during the the test tray process, Dietary Staff #2 said she used to be the Food Service Supervisor at the facility and was at the facility today to assist the Dietary Department. The surveyor and Dietary Staff #2 observed the pureed asparagus and Dietary Staff #2 said

she saw the thin, flat pieces of asparagus that had not been prepared to be smooth. Dietary Staff #2 said there should not be any lumps or whole pieces in pureed food items and that all pureed foods should be prepared to be smooth. Dietary Staff #2 said asparagus was hard to puree due to its outer skin-like texture and that the [NAME] should have substituted with an alternate vegetable, such as green beans, that would blend more smoothly for residents requiring pureed foods.

Review of the facility's document titled Order Text Search for Pureed Diets dated 3/25/25, indicated nine residents in the facility had orders for pureed diets when the pureed diet test tray was conducted on 3/19/25.

During an interview on 3/25/25 at 10:46 A.M., Dietary Staff #3 said she was a [NAME] at the facility. Dietary Staff #3 said when pureeing food, she uses the emulsion blender and adds liquid to ensure that the food is of pudding-like consistency. Dietary Staff #3 said if food items are not the appropriate consistency, like the pureed asparagus with pieces of the skin remaining, a strainer could be used with additional liquid to strain

the asparagus. Dietary Staff #3 said once strained, food thickener could be added to the asparagus to ensure it is the appropriate consistency.

50563

2. On 3/19/25, the surveyor observed the following during lunch meal tray pass on Unit Four:

-First tray cart arrived to the unit at 12:01 P.M. and staff began serving from the cart immediately.

-Completed serving first tray cart at 12:11 P.M.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 -Second tray cart arrived to unit at 1:04 P.M.

Level of Harm - Minimal harm or -Staff began serving trays from the second cart at 1:05 P.M. potential for actual harm -Third tray cart arrived to the unit at 1:06 P.M. Residents Affected - Few -The last tray was served from the second tray cart at 1:13 P.M., and staff began serving trays from the third tray cart.

-At 1:19 P.M. one tray from the third tray cart remained unserved and Minimum Data Set (MDS) Nurse #2 was observed saying to fell ow staff that the remaining tray was waiting for a staff member to be able to assist that Resident to eat.

-At 1:21 P.M., the last tray from the third tray cart was served 15 minutes after the tray cart arrived to the unit.

On 3/19/25 at 1:21 P.M., the surveyor conducted a lunch meal test tray on Unit Four with MDS Nurse #2 testing food temperatures and test tray results as follows:

-Carrots: 94 degrees Fahrenheit (F) and was lukewarm to taste

-Pasta: 80 degrees F and was cool to taste

-Ground Chicken with Gravy: 86 degrees F and lukewarm to taste

-Coffee: 118 degrees F and hot to taste

-Milk: 48 degrees F and cool to taste

During an interview immediately following the test tray completion, MDS Nurse #2 said that food temperatures in the 80s was too cold and that she would expect food to be served hotter to the Residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42741

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide safety and awareness related to resident's food allergies for two Residents (#163 and #215) out of a total sample of 36 residents.

Specifically,

1. For Resident #163, the facility failed to ensure that the Resident with a chocolate allergy was not provided with food that included the documented allergen.

2. For Resident #215, the facility failed to maintain Resident safety relative to a coconut allergy putting him/her at risk for anaphylaxis (a life-threatening allergic reaction).

Findings include:

1. Resident#163 was admitted to the facility in December 2024 with diagnoses including Alzheimer's Disease.

Review of the recent comprehensive Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident #163:

-required substantial to max assist to eat his/her meals

-long-term memory and short-term memory were impaired.

Review of Resident #163's Nursing/Dietary Communication form dated 10/9/24, indicated the Resident was allergic to chocolate.

Review of Resident #163's meal ticket dated 3/19/25, indicated the Resident was allergic to chocolate flavoring, chocolate, and cocoa.

On 3/19/25 at 12:44 P.M., the surveyor observed Resident #163 seated in the unit dining room and was actively being assisted with his/her lunch meal. The surveyor observed a round bowl containing a pureed chocolate dessert on the Resident's tray. The surveyor requested that Unit Manager (UM) #2 review the Resident's meal ticket and tray. UM #2 said Resident #163 was allergic to chocolate and should not have been served the chocolate dessert at the lunch meal.

During an interview on 3/19/25 at 2:00 P.M., the Food Services Supervisor said Resident #163 had documentation on his/her meal ticket indicating he/she was allergic to chocolate and the pureed chocolate cake should not have been on his/her lunch meal tray. The Food Services Supervisor said food allergens making their way up to the Units on meal trays was an ongoing issue in the facility and was currently being monitored by a Performance Improvement Plan (PIP).

42690

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0806 2. Resident #215 was admitted to the facility in December 2024 with diagnoses including Anaphylactic Shock and mild cognitive impairment. Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident #215:

Residents Affected - Few -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.

Review of Resident #215's current allergy list indicated the following food allergies and the possible outcomes if consumed:

-Nuts: Rash

-Seafood: Anaphylaxis

-Honey Bee Venom Protein: Anaphylaxis

-Coconut: Anaphylaxis

Review of the March 2025 Physician orders indicated the following:

-House regular diet, regular texture, thin liquids with meals and NO food allergies.

-Epinephrine 0.3 MG (milligrams)/0.3 ML (milliliters) solution Injection as needed (PRN) once a day for Anaphylactic shock.

Review of Resident #215's meal ticket dated 3/24/25, indicated:

-Turkey Breast with apple Normandy

-Turkey Chef Salad

-Corn Bread Stuffing

-Buttered Garden Blend Vegetable

-Wheat Bread

-Margarine

-Fresh Whole Banana

-2% Lactaid Milk

-Hot Coffee

-Creamer

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0806 -1 salt, 1 pepper, 1 sugar

Level of Harm - Minimal harm or ALLERGIES: All Nuts/nut Products; All fish/fish sauce ingredient; All shellfish ingredients; Coconut oil; potential for actual harm Coconut

Residents Affected - Few On 3/24/25 at 2:09 P.M., Resident #215 asked if he/she could speak with the surveyor stating that he/she was very upset about what happened at lunch. During an interview at the time, Resident #215 said while at lunch today in the first-floor main dining room, he/she was served a custard dessert. Resident #215 said when he/she took a bite he/she could tell the texture was off and quickly realized the dessert was made with coconut, which he/she is allergic to. Resident #215 said that he/she immediately notified Unit Manager (UM) #3, who was in the dining room. Resident #215 said that UM #3 immediately removed the dessert and assessed the Resident. Resident #215 said that he/she was okay, most likely because he/she had only had two small bites.

During an interview on 3/24/25 at 2:30 P.M., Nurse #7 said that the Nurse who was in the dining room called immediately to notify her that Resident #215 had eaten a small amount of the dessert containing coconut. Nurse #7 said that Resident #215 arrived on the unit shortly after, at which point Nurse #7 assessed the Resident and offered Benadryl medication, which the Resident declined.

During an interview on 3/24/25 at 2:43 P.M., the Food Service Director (FSD) said that he himself went to the main dining room to check on allergies and reminded staff to pay attention to the allergies listed. The FSD said he felt confident that Resident #215 would not get the custard dessert and it was his understanding that

the Resident did not get the dessert.

During an interview on 3/24/25 at 2:48 P.M., UM #3 said that the Resident had been served the coconut (custard)dessert during lunch, and she was the one who removed the coconut dessert from the table after

the Resident asked what was in it due to the texture not feeling right. UM #3 said that she did not see the Resident eat the coconut dessert and could not tell if bites had been taken out of it because the coconut dessert was cut up, but the Resident did have food in his/her mouth. UM #3 said that the meal ticket indicated Resident #215 had a coconut allergy and the allergies were highlighted. UM #3 said that the dessert was not listed on the dietary slip/menu nor was it labeled with what type of custard. UM #3 further said that the coconut dessert never should have been on the tray to begin with but would not have known differently because it was not labeled coconut dessert.

Please Refer to

F-F867.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 37400

Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure that the facility main kitchen was maintained in a clean and sanitary manner to prevent contamination and the spread of foodborne illnesses.

Specifically, the facility staff failed to ensure:

-food for resident consumption was stored appropriately and were labeled and dated.

-equipment used for meal preparation were clean and free of debris when not in use.

-fans utilized in the kitchen remained dust free preventing potential physical contamination.

-an issue with the facility dish machine was identified when the minimum wash temperatures were not obtained, as required.

Findings include:

Review of the facility policy titled Dietary: Sanitary Conditions, revised 9/21/22, indicated that the facility will follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness.

The policy also included the following:

-safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues through the facility's food handling process

-Types of food contamination include physical contamination

-Factors implicated in foodborne illness include contaminated equipment

>improper equipment sanitation procedures

-Food Receiving and Storage

>when food is purchased by the nursing home, inspection for safe transport and quality upon receipt and proper storage helps ensure its safety

>Keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer is indicated.

>practices to maintain safe refrigerator storage include: labeling, use by dating and monitoring refrigerated foods, including but not limited to leftovers, so it is used by it's used by date, frozen (if applicable) or discarded.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 -Equipment and Utensil Cleaning and Sanitization

Level of Harm - Minimal harm or >potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of contaminated potential for actual harm equipment.

Residents Affected - Many >protecting equipment fro contamination via splash, dust, grease, etc. is indicated

>Dishwashing machines, operated according to manufacturers specifications, wash, rinse and sanitize dishes and utensils using either heat or chemical sanitization.

>High Temperature Dish machine (heat sanitization)

-wash 150- 165 degrees Fahrenheit wash, and

-final rinse- 180 degrees Fahrenheit final rinse .

-When cleaning fixed equipment (mixers, slicers and other equipment that cannot be readily immersed in water), the removable parts are washed and sanitized and non-removable parts are cleaned with detergent and hot water, rinsed, air dried and sprayed with sanitizing solution (at the effective concentration).

On 3/18/25 at 7:20 A.M., the surveyor conducted an initial tour of the facility main kitchen and the following was observed:

-walk-in refrigerator had a sheet pan of raw hamburger and clear packages of thawed cut up chicken that were not labeled or dated

-the window behind the steam table was open and had no screen

-the industrial can opener had built up black thick debris on the blade

-the slicer had light colored debris on the blade and surrounding parts of the machine

-an unlabeled and undated large bin containing flour. The outside top of the bin was tacky to the touch and was visibly dirty on the outside and on the sliding cover

During an interview at the time, Dietary Staff #3, who was the [NAME] said the sheet pan of hamburger and

the chicken were pulled yesterday from the freezer to be thawed. Dietary Staff #3 said there should be labels and dates on both items.

On 3/25/25 at 10:16 A.M., the surveyor conducted a follow-up walk through of the facility main kitchen with

the Food Service Director (FSD) and the following was observed:

-the bin containing flour remained dirty on the outside

-the slicer had light colored debris on the blade and on the surrounding parts of the machine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 During an interview at the time, Dietary Staff #3 said the slicer had not been used since the previous day when slicing turkey and was cleaned after its use. Level of Harm - Minimal harm or potential for actual harm -two fans that were in use (on) and were attached to the walls in the dish room were dust laden. One fan was located where clean dishware was stored. Residents Affected - Many -the dish machine was in use and the wash temperature was 140 degrees Fahrenheit [F] (after running several racks of dishes through the machine) and the final rinse temperature was ranging from 180- 190 degrees F.

During an interview with the FSD immediately following the observations, the FSD said:

-the inside of the flour bin was cleaned out weekly, but the outside of the bin needed to be cleaned

-the slicer was not thoroughly cleaned and needed to be cleaned again

-the kitchen windows should not be open if there were no screens because it could allow pests (mice/bugs) to enter the kitchen

-both of the fans that were in use in the dish room needed to be cleaned because they were covered in dust

-the minimum dish machine wash temperature should be 160 degrees F. The FSD further said he had checked the temperature that morning and it was within range. The FSD said that the dish machine should not be used and he would contact their vendor for further instructions.

During an interview on 3/25/25 at 10:46 A.M., Dietary Staff #3 said she keeps instructing staff to keep the window in the kitchen closed because there was no screen. Dietary Staff #3 said she has also been educating the dietary staff about ensuring kitchen equipment, like the can opener and surfaces were cleaned

after every use because they could be a cause of potential cross contamination.

During a follow-up interview on 3/25/25 at 11:08 A.M., the FSD said he spoke with the vendor relative to the facility dish machine and was instructed to connect the chemical sanitizer and the dish machine would be safe to use until they were able to provide an on-site visit to remedy the wash temperature issue. The FSD said the temperatures were taken in the beginning when the dish machine was used and the wash temperature was 167 degrees F. The FSD said the machine had been running for a while when he and the surveyor observed the wash temperatures of 140 F, and that the staff using the dish machine should be monitoring the temperatures to ensure they are within the acceptable ranges.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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

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

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 42741

Residents Affected - Some Based on interview, and record review, the facility failed to implement corrective and preventive actions and re-evaluate a performance improvement plan (PIP) when the identified interventions were no longer making progress toward the identified goal for reducing the amount of food allergens that were sent to residents on meal trays.

Specifically, the facility failed to ensure that an effective system was maintained for implementing changes and monitoring performance putting residents in the facility at risk for significant harm relative to ingesting a food allergen.

Findings include:

Review of the facility Quality Assurance and Performance Improvement (QAPI) Plan, undated, indicated the following:

-Purpose and Goals

-Take a proactive approach to continually improve the way we care for and engage with our residents/clients, caregivers, and other partners .

-Guiding Principles:

-Uses QAPI to make decisions and guide our day to day operations.

-Makes decisions based on data .

-Collects and monitors data related to the outcomes of subpopulations .and uses the data to determine QAPI initiatives.

-Sets goals for performance using internal and external benchmarks and measures progress towards those goals.

-Feedback, Data Systems and Monitoring:

-The QAPI Team will meet monthly to review the analysis, trends, and action items from the data compiled within appropriate time frame as indicated. The QAPI team will evaluate and gather data on the system processes to evaluate their effectiveness.

-Systemic Analysis and Systemic Action :

-Will focus on making changes to systems and processes rather than focusing on addressing individual behaviors to minimize the risk of problem reoccurring.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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

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

F 0867 -Root Cause Analysis (RCA) underpins all the performance improvement activities of this organization. The Change team may use any of the following methods: Level of Harm - Minimal harm or potential for actual harm -Barrier exercise-mind, system, information, leader barriers

Residents Affected - Some -Swiss cheese model-management, organization, programmatic, or individual barriers

-5 Why's-asking why until cause determined

-Fishbone diagram

During the survey period of 3/18/25 through 3/21/25, and 3/24/25 through 3/25/25, the following occurred:

-During the initial screening process on 3/18/25 one Resident reported he/she had concerns as he/she had been served meals that contained food items that he/she had listed as an allergen.

-On 3/19/25 at 12:44 P.M., the surveyor observed Resident #163 was actively being assisted with his/her lunch meal and a round bowl containing a pureed chocolate dessert on the Resident's tray. The surveyor requested Unit Manager (UM) #2 intervene and remove the chocolate dessert from the Resident's tray as Resident #163 had a documented allergy on his/her meal ticket of chocolate flavoring, chocolate, and cocoa.

-On 3/24/25 at 2:09 P.M., Resident #215 told a surveyor that he/she had received a dessert at lunch that contained coconut, an ingredient that he/she had a listed allergen. Following the incident Nurse #7 said Resident #215 was allergic to coconut, that Nurse #7 had assessed Resident #215 and offered the Resident Benadryl (an antihistamine).

-27 Residents who resided in the facility have been identified by the facility as having a food allergy.

During an interview on 3/19/25 at 2:00 P.M., the Food Services Supervisor said the facility was currently doing a PIP for QAPI regarding allergens being served on meal trays. The Food Services Supervisor said allergens being served on meal trays had been an ongoing issue within the facility.

Review of the PIP documentation indicated the following:

September 2024

-the first QAPI meeting the PIP information was provided to the committee about accuracy of meal trays relative to allergies.

-Accuracy of allergy trays sent to the units was 95.5% accurate.

-The Goal was 100% accuracy.

-Plan of correction was to continue with tray audits.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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

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

F 0867 -No target date for achieving the 100% accuracy goal was identified in notes that were provided.

Level of Harm - Minimal harm or -No audit tools were provided to correspond with how the facility reached the 95.5% accuracy for the tray potential for actual harm audits.

Residents Affected - Some October 2024

-Accuracy of allergy trays sent to the units was 91.7% accurate.

-The Goal was 100% accuracy.

-Plan of correction was to continue with tray audits, and to highlight allergies in different colors on meal tickets.

-No target date for achieving the 100% accuracy goal was identified in notes that were provided.

-No audit tools were provided to correspond with how the facility reached the 91.7% accuracy for tray audits.

-No in-servicing documentation was provided to show what staff members had been in-serviced.

November 2024

-Accuracy of allergy trays sent to the units was 90% accurate.

-The Goal was 100% accuracy.

-Plan of correction was to continue to audit trays, highlighting allergies in different colors, new cart order system to be implemented which was allergy trays to be the first trays placed in carts, and specific food service employees were to be trained for ensuring tray line accuracy.

-No target date for achieving the 100% accuracy goal was identified in the notes that were provided.

-No audit tools were provided to correspond with how the facility reached the 90% accuracy for tray audits.

-No in-servicing documentation was provided to show what staff members had been in-serviced

December 2024

-Accuracy of allergy trays sent to the units was 94.7% accurate.

-The Goal was 100% accuracy.

-Plan of correction was to continue with tray audits, highlighting allergies in different colors, a new cart order system to be implemented with allergy trays to be the first trays placed in the carts, and specific food service employees were to be trained for ensuring tray line accuracy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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

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

F 0867 -No new interventions were implemented at this time.

Level of Harm - Minimal harm or -No target date for achieving the 100% accuracy goal was identified in the notes that were provided. potential for actual harm -No audit tools were provided to correspond with how the facility reached the 94.7% accuracy for tray audits. Residents Affected - Some -No in-servicing documentation was provided.

January 2025

-Accuracy of allergy trays sent to the units was 96.3% accurate.

-The Goal was 100% accuracy

-Plan of correction was to continue to with tray audits,, highlighting allergies in different colors, a new cart order system to be implemented with allergy trays to be the first trays placed in carts, and specific food service employees were to be trained for ensuring tray line accuracy.

-No new interventions were implemented this month.

-No target date for achieving the 100% accuracy goal was identified in the notes that were provided.

-No audit tools were provided to correspond with how the facility reached the 96.3% accuracy for tray audits.

-No in-servicing documentation was provided.

February 2025

-Accuracy of allergy trays sent to the units was 93.6% accurate.

-The Goal was 100% accuracy.

-Plan of correction was to continue with tray audits, highlighting allergies in different colors, a new cart order system to be implemented with allergy trays to be first trays placed in carts, and specific food service employees were to be trained for checking tray line accuracy.

-No new interventions were implemented this month.

-No target date for achieving the 100% accuracy goal was identified in the notes that were provided.

-No audit tools were provided to correspond with how the facility reached the 93.6% accuracy for tray audits.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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

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

F 0867 -No in-servicing documentation was provided.

Level of Harm - Minimal harm or The facility provided documentation to the survey team for one in-service titled Accurate Tray Card Reading potential for actual harm and Allergies, that completed with the dietary staff from 3/4/25 through 3/8/25.

Residents Affected - Some During an interview on 3/24/25 at 2:29 P.M., the Food Services Supervisor said the dietary department had been doing a PIP since August 2024, relative to ensuring residents received the correct diets on their meal trays, and were not provided with food that contained an allergen. The Food Service Supervisor said she was unable to locate the audit tools used monthly for the PIP and was also unable to locate any in-servicing that had been done as part of the PIP.

During a follow-up interview with the Food Service Director (FSD) and the Food Service Supervisor on 3/25/25 at 9:22 A.M., the FSD said the current auditing process was to check ten meal trays randomly during each meal to ensure meal accuracy and ensure allergens were not going to be served to a resident with an allergy. The Food Services Supervisor said staff not only monitored accuracy of trays during the tray line, a senior staff member double checked the trays at the completion of the tray line, and the trays were to be checked by the Nursing Unit Manager once the trays arrived on the units. The Food Services Supervisor said that even with the multi-check system, allergens were still being served on meal trays. The surveyor asked

the FSD and the Food Service Supervisor what the concern would be if only checking ten trays randomly when there was a known problem of allergens being served. Both the FSD and Food Services Supervisor said they risked missing a tray of a resident who did have allergies, and they should have been monitoring all allergy trays prior to them leaving the kitchen. The FSD said the PIP was not effective and due to the severity of the concern being addressed in the PIP he would have expected the goal for the project to only have been one month and the fact that it has gone on for many months without resolve was concerning and put residents at risk for having an allergic reaction.

During an interview on 3/25/25 at 11:36 P.M., the Administrator said the current PIP relative to food allergens had not been effective and the team needed to take a deeper look into the problem.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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

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

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47901 potential for actual harm Based on observation, interview, and record review, the facility failed to implement infection control practices Residents Affected - Some in accordance with professional standards of practice to prevent the potential spread of infection for one Resident (#209), out of a total sample of 36 residents, and on four units (Unit 1, Unit 2, Unit 3 and Unit 4) out of five units.

Specifically, the facility failed to:

-ensure the appropriate precautions were initiated timely when Resident #209 was identified with gastrointestinal symptoms (nausea and vomiting) increasing the risk for the spread of infection to other residents and staff.

-initiate norovirus outbreak monitoring timely resulting in the spread of infection to Unit's 1, 2, 3, and 4.

Findings include:

Review of CDC Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, revised March 21, 2024, retrieved from, https://www.cdc. gov/infection-control/hcp/norovirus-guidelines/summary-recommendations.html indicated:

-Avoid exposure to vomitus or diarrhea. Place patients on Contact Precautions in a single occupancy room if

they have symptoms consistent with norovirus gastroenteritis.

-When patients with norovirus gastroenteritis cannot be accommodated in single occupancy rooms, efforts should be made to separate them from asymptomatic patients. Dependent upon facility characteristics, approaches for cohorting patients during outbreaks may include placing patients in multi-occupancy rooms, or designating patient care areas or contiguous sections within a facility for patient cohorts.

-During outbreaks, place patients with norovirus gastroenteritis on Contact Precautions for a minimum of 48 hours after the resolution of symptoms to prevent further exposure of susceptible patients.

-Consider minimizing patient movements within a ward or unit during norovirus gastroenteritis outbreaks.

-Consider restricting symptomatic and recovering patients from leaving the patient-care area unless it is for essential care or treatment to reduce the likelihood of environmental contamination and transmission of norovirus in unaffected clinical areas.

-Consider suspending group activities (e.g., dining events) for the duration of a norovirus outbreak.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 -If norovirus infection is suspected, adherence to PPE use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry) to reduce the Level of Harm - Minimal harm or likelihood of exposure to infectious vomitus or fecal material. potential for actual harm -Use a surgical or procedure mask and eye protection or a full-face shield if there is an anticipated risk of Residents Affected - Some splashes to the face during the care of patients, particularly among those who are vomiting.

-For those affected areas where it is necessary to have continued visitor privileges during outbreaks, screen and exclude visitors with symptoms consistent with norovirus infection and ensure that they comply with hand hygiene and Contact Precautions.

-Provide education to staff, patients, and visitors, including recognition of norovirus symptoms, preventing infection, and modes of transmission upon the recognition and throughout the duration of a norovirus gastroenteritis outbreak.

-Begin active case-finding when a cluster of acute gastroenteritis cases is detected in the healthcare facility. Use a specified case definition and implement line lists to track both exposed and symptomatic patients and staff. Collect relevant epidemiological, clinical, and demographic data as well as information on patient location and outcomes.

Review of the facility policy titled Outbreak Investigation, initiated September 2011, indicated:

-It is the policy of facility that outbreak measures will be instituted whenever there is an incidence of infection above what would normally be expected.

-The Infection Preventionist (IP) will have the authority to implement control measures as appropriate, in coordination with facility administration and medical staff.

Purpose:

a) To establish that an outbreak exists.

b) To provide timely, appropriate monitoring of ill residents.

c) To prevent the transmission of infection from one resident to others.

d) To provide facility employees, medical and administrative staff, and state/local agencies to accurate, organized, and objective information.

e) To prevent future outbreaks of similar illness.

-The importance of handwashing, compliance with isolation precautions and the benefit to prevent outbreaks.

-Get the facts yourself! Confirm that symptoms really exist by chart review, and ask the following questions:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 -If gastrointestinal illness is reported:

Level of Harm - Minimal harm or a) How many loose stools in a 24-hour period? potential for actual harm b) Have any resident experienced loose stools, document the information on a line list. Residents Affected - Some c) Are there other symptoms, example, nausea, vomiting or diarrhea?

-Look for new cases.

-Keep records of how events transpired.

-Educate staff, residents and visitors.

1. Resident #209 was admitted to the facility in October 2024 with diagnoses including Cerebrovascular Accident (CVA), Diabetes, and Hypertension.

Review of Resident #209's Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of total possible 15.

Review of Resident #209's Nursing Progress Note dated 3/19/25 at 8:18 P.M. indicated the Resident had nausea, vomited, refused dinner, and dinnertime Insulin medication. The Nursing Progress Note further indicated ginger ale was offered to the Resident, but he/she was afraid to consume due to nausea and vomiting.

On 3/20/25 at 7:59 A.M., the surveyor observed Resident #209 was lying in bed asleep. The surveyor also observed there was no precaution sign (s) posted at Resident #209's room.

During an interview on 3/20/25 at 11:12 A.M., the IP said there were no active infections other than residents that had been placed on Enhanced Barrier Precautions (EBP - targeted infection prevention strategy, focusing on gown and glove use during high-contact resident care activities, to reduce the transmission of multi-drug-resistant organisms [MDROs] in the facility). The IP further said Resident #209 would not be discharged home as planned due to the Resident not feeling well.

On 3/20/25 at 2:37 P.M., the surveyor observed Contact Precaution signage was posted on Resident #209's door, that indicated staff should wear gown and gloves before entering the Resident's room.

During an interview on 3/20/25 at 3:02 P.M., Unit Secretary #2 said Resident #209 was in the activity room playing bingo.

During an interview on 3/20/25 at 3:06 P.M., Nurse #9 said Resident #209's discharge was on hold due to

the Resident being sick with nausea and vomiting that began in the evening on 3/19/25. Nurse #9 said the Resident had refused breakfast and lunch on 3/20/25. Nurse #9 said Resident #209 would be in his/her room and if the Resident came out of the room, the Resident would be wearing a mask.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 3/20/25 at 3:12 P.M., the surveyor observed Resident #209 seated in a wheelchair in the activity room with eight other residents playing bingo. The surveyor did not observe Resident #209 wearing a mask. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/20/25 at 3:16 P.M., the Corporate Infection Preventionist (CIP) said it was just brought to his/her attention that three Residents had diarrhea, and that the facility was reviewing these Residents Affected - Some reports.

During an interview on 3/20/25 at 3:18 P.M., the IP said she was aware Resident #209 had vomiting and diarrhea in the morning and had placed a Contact Precaution sign at the Resident's door. The IP further said

she had been made aware that two other Residents had started with nausea and vomiting on the same unit as Resident #209.

During an interview on 3/20/25 at 3:27 P.M., Activity Assistant (AA#1) said she was not aware that any residents had nausea and vomiting at the facility.

During an interview on 3/21/25 at 11:14 A.M., the IP provided a line listing that indicated that four Residents including Resident #209 had nausea and vomiting with symptom onset as of 3/20/25. The IP said Resident #209 should not have attended the bingo activity without a mask and proper hand hygiene. The surveyor and

the IP reviewed the line listing, and the IP said she was not aware that the GI symptom onset was 3/19/25 and had not reviewed Resident #209's progress notes. The surveyor, IP, and CIP, reviewed Resident #209's progress note dated 3/19/25 at 8:18 P.M., indicating the Resident was experiencing nausea and vomiting.

The IP said Resident #209 should have been placed on Contact Precaution as soon as his/her symptoms were identified on 3/19/25 to avoid the spread of the virus but he/she was not placed on precautions. The IP further said Resident #209 should not have attended the bingo activity with other residents.

During an interview on 3/25/25 at 10:18 A.M., the IP and CIP provided a line listing that indicated fifteen other residents had developed nausea and vomiting and one resident was hospitalized . The IP further said six out of the total 16 residents on the line listing for the outbreak were on Unit 2, the same unit as Resident #209, seven of the residents resided on Unit 4, one resident resided on Unit 3, and one resident resided on Unit 1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50138 potential for actual harm Based on record review, and interview, the facility failed to provide a Pneumococcal Immunization to one Residents Affected - Few Resident (#25) of five applicable residents, out of a total sample of 36 residents.

Specifically, the facility failed to administer an updated Pneumococcal Immunization to Resident #25 within

the appropriate timeframe as indicated by CDC (Centers for Disease Control and Prevention) guidelines placing Resident #25 at increased risk for complications associated with Pneumococcal infection.

Findings include:

Review of CDC guidelines for Pneumococcal immunization at www.cdc.gov indicated that adults who have received the Pneumococcal Polysaccharide Vaccine 23 (PPSV23) Immunization after age [AGE] years should have shared clinical decision making to decide whether to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) Immunization one year after the PPSV23 had been administered.

Review of the facility policy titled Resident Pneumococcal Immunization, dated September 2011, revised 9/1/23, included but was not limited to:

-Residents of the facility will be offered immunization to protect them from Pneumococcal disease.

-Pneumococcal immunization will be provided as recommended by the CDC.

-Residents will be offered immunization to protect them from Pneumococcal disease.

-A written consent for immunization is required.

Resident #25 was admitted to the facility in June 2024 with diagnoses including Heart Failure and was over

the age of 65.

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated that Resident #25 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of

a possible total score of 15.

Review of Resident #25's Medical Record indicated:

-received PPSV23 immunization in February 2021.

-signed an immunization administration consent form for PCV20 in June 2024.

-No evidence that the PCV20 immunization had been administered since the immunization consent form was signed in June 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 74 225687 Department of Health & Human Services Printed: 09/04/2025 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 225687 B. Wing 03/25/2025

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

Hillcrest Commons Nursing & Rehabilitation Center 169 Valentine Road Pittsfield, MA 01201

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 0883 During an interview on 3/24/25 at 11:34 A.M., the Director of Nursing (DON) said that Resident #25 had received the PPSV23 Immunization in February 2021 prior to admission to the facility. The DON said that he Level of Harm - Minimal harm or was unaware if Resident #25 had been provided/offered additional Pneumococcal immunization since potential for actual harm admission to the facility.

Residents Affected - Few During an interview on 3/24/25 at 4:16 P.M., the Infection Preventionist (IP) said that she was responsible to obtain resident consent for Pneumococcal immunizations and tracking immunizations in the facility. The IP said that Resident #25 had signed consent for Pneumococcal immunization in June 2024. The IP said that once a Resident had given consent for Pneumococcal immunization an order should be obtained from the Provider and the immunization solution ordered from the pharmacy. The IP said that residents should be immunized within seven days of consent being signed. The IP said that Resident #25 had not yet been immunized with PCV20. The IP said that Pneumococcal immunization was important to stop the transmission of infection within the facility.

During an interview on 3/25/25 at 8:37 A.M., the DON said the facility followed the CDC guidelines for Pneumococcal immunization. The DON said that Resident #25 was due for PCV 20 immunization at the time of admission to the facility in June 2024. The DON said that Resident #25 should have been administered

the PCV20 in June 2024 when the Resident had signed the consent form but was not administered the vaccine. The DON said that Pneumococcal immunization was important to prevent complications from Pneumococcal disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 74 225687