West Newton Healthcare

F-F677

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Level of Harm - Minimal harm or 44095 potential for actual harm Based on observations, interviews, and record review, the facility failed to identify and assess the use of an Residents Affected - Few abdominal binder as a potential restraint for one Resident (#74) out of a total sample of 24 residents.

Findings include:

Review of the facility policy titled, Use of Restraints, dated as revised 1/24, indicated that restraints shall only be used for the safety and well-being of the residents) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms) and never for discipline or staff convenience, or for the prevention of falls.

-Guidelines

1. Physical Restraints are defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.

2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition and this restricts his/her typical ability to change position or place, that device may be considered a restraint.

3. Restraints may be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint maybe required to:

a. Treat the medical symptom;

b. Ensure the resident's safety; and/or

c. Assist the resident attain the highest level of his/her physical or psychological well-being

4. Prior to placing a resident in restraints, there shall be a pre-restraining evaluation and review to determine

the need for restraints. The evaluation shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.

6. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.

7. Residents and/or HCP shall be informed about the potential risks and benefits of the use of the restraint

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0604 8. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. Level of Harm - Minimal harm or potential for actual harm Resident #74 was admitted to the facility in January 2023 with diagnoses including traumatic brain injury, history of falling, and muscle weakness. Residents Affected - Few

Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #74 was rarely/ never understood. The MDS further indicated Resident #74 rejected care, was dependent on staff for activities of daily living and had a feeding tube. The MDS indicated Resident #74 did not require physical restraints.

Review of Resident #74's current physician's order, with a start date of 5/25/23, indicated:

-May order and apply abdominal binder to secure PEG (feeding tube inserted into the stomach) tube. Apply and secure binder when PEG tube is not in use. Monitor for skin breakdown and notify MD, NP, or PA. Patient at high risk for accidental self-removal of PEG tube, please secure when not in use to reduce risk of trauma and infection to PEG site.

-When PEG tube is not in use, please secure PEG tube using skin safe tape and gauze. Patient high risk of accidental self-removal of PEG tube, please secure when not in use to reduce risk of trauma.

Review of Resident #74's NSH Nursing Evaluation - V 18, dated 4/23/24, 7/19/24, 10/12/24 and 1/4/25, indicated:

-Section M. Restraints instructions: Restraints = Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts the freedom of movement or normal access to one's body.

1. Is the resident currently using a restraint? Coded as no.

Review of Resident #74's plan of care on 1/6/25 failed to include documentation to support the use of the abdominal binder.

Review of Resident #74's medical record on 1/6/25 failed to include a consent from the Resident's health care agent consenting to the use of the abdominal binder.

On 1/8/25 at 12:51 P.M., the surveyor observed the abdominal binder across Resident #74's abdomen. Nurse #4 said that Resident #74 was wearing an abdominal binder so he/she cannot pull out the g-tube. Resident #74 was unable to self-release the abdominal binder on command.

During an interview on 1/9/25 at 7:36 A.M., Certified Nursing Assistant (CNA) #2 said Resident #74 is totally dependent for care and Resident #74 is supposed to wear an abdominal binder at all times so he/she doesn't pull the tube out.

During an interview on 1/9/25 at 9:23 A.M., the Director of Clinical Operations #2 said the use of restraints requires quarterly assessments. She reviewed the regulatory requirements for restraint use and said that Resident #74 should be able to self-release the abdominal binder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0604 On 1/9/25 at 11:08 A.M., the surveyor observed the Director of Clinical Operations #2 assess Resident #74's abdominal binder. Resident #74 was unable to remove the abdominal binder on command. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or 44095 potential for actual harm Based on record review and interview, the facility failed to ensure that Minimum Data Set (MDS) Residents Affected - Few assessments were coded accurately for one Resident (#26) out of a total sample of 24 Residents. Specifically, for Resident #26 the facility failed to code oxygen use on the MDS assessment.

Findings include:

Resident #26 was admitted to the facility in October 2022 with diagnoses including emphysema, chronic obstructive pulmonary disease (COPD), and anxiety.

Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/24, indicated that Resident #26 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 14 out of 15. The MDS further indicated Resident #26 required assistance with activities of daily living and did not require oxygen administration.

Review of Resident #26's physician's progress note, dated 11/1/24, indicated Resident has a history of severe COPD with chronic oxygen use at 2 liters per minute.

Review of Resident #26's current physician's order, with a start date of 11/11/23, indicated:

-Obtain oxygen saturation every shift and administer oxygen at 2 liters per minute (LPM).

Review of Resident #26's Treatment Administration Record (TAR), dated November 2024, indicated between 11/1/24 and 11/8/24 Resident #26 received oxygen at 2 LPM every shift.

Review of Resident #26's plan of care related to respiratory status, dated as revised 11/21/24, indicated:

-Oxygen settings: oxygen via nasal cannula as ordered.

During an interview on 1/7/25 at 1:32 P.M., the Director of Clinical Operations #2 said she reviewed the MDS for 11/8/24 and the MDS Nurse should have coded the oxygen use but did not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm 41105

Residents Affected - Few Based on observation, record review and interview the facility failed to ensure they developed and implemented a comprehensive person-centered care plan for four Residents (#90, #73, #24, #74) out of a total sample of 24 residents. Specifically:

1. For Resident #90 the facility failed to ensure the bed was in the lowest position and floor mats were in place when the resident was in bed, as ordered by the physician.

2. For Resident #73 the facility failed to develop a person-centered comprehensive care plan for a diagnosis of history of suicidal ideation.

3. For Resident #24 the facility failed to develop a care plan for the use of psychotropic medications.

4. For Resident #74 the facility failed to implement padded side rails.

Findings include:

1. Resident #90 was admitted to the facility in May 2024 and has diagnoses that include dementia without behavioral disturbance and muscle weakness.

Review of the most recent Minimum Data Set (MDS) assessment, dated 9/30/24, indicated that Resident #90 was assessed by staff to have severe cognitive impairment, The MDS further indicated Resident #90 required substantial to maximal assist with bed mobility.

Review of the most Nursing Evaluation, dated 12/23/24, indicated Resident #90 had sustained 1-2 falls within the last six months.

Review of the current physician's orders indicated the following order:

-Make sure the bed is in the lowest position and floor mats are in place when resident is in bed, start date 8/1/24.

On 1/6/25 at 8:51 A.M., Resident #90 was observed asleep in bed. The bed was at a regular height and there was a fall mat on the left side of the bed, but none on the right side. A second fall mat was not observed in the room.

On 1/7/25 at 6:54 A.M., Resident #90 was observed asleep in bed. The bed was in the lowest position, however there was no fall mat on the right side of the bed, only on the left. A second fall mat was not observed in the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0656 On 1/7/25 at 7:54 A.M., Resident #90 was observed asleep in bed. The bed was in the lowest position, however there was no fall mat on the right side of the bed, and the fall mat on the left side of the bed was Level of Harm - Minimal harm or now 2-3 feet away from the bed, exposing Resident #90 directly to the floor should he/she fall. A second fall potential for actual harm mat was not observed in the room.

Residents Affected - Few On 1/7/25 at 9:56 A.M., Resident #90 was observed asleep in bed. The bed was in the lowest position, however there was no fall mat on the right side of the bed, and the fall mat on the left side of the bed was now 2-3 feet away from the bed, exposing Resident #90 directly to the floor should he/she fall. A second fall mat was not observed in the room.

On 1/9/25 at 7:25 A.M., Resident #90 was observed asleep in bed. The bed was at a regular height and there was a fall mat on the left side of the bed, but none on the right side. A second fall mat was not observed in the room.

On 1/9/25 at 8:13 A.M., Resident #90 was observed asleep in bed. The bed was at a regular height and there was a fall mat on the left side of the bed, but none on the right side. A second fall mat was not observed in the room.

During an interview on 1/9/25 at 11:31 A.M., with Resident #90's Certified Nursing Assistant (CNA) #4 she said that she was not aware that Resident #90's bed was supposed to be in the lowest position with fall mats

in place. CNA #90 said that she usually gets report at the start of a shift on a resident's care needs but because she was moved to the floor at 10:30 A.M., that morning she had not.

During an interview on 1/9/25 at 11:39 A.M., Nurse #6 said she is Resident #90's nurse. She said that it was

the expectation that nursing staff follow Physician orders. Nurse #6 said that staff should maintain Resident #90's bed in the lowest position with fall mats in place if there was an order for that. Nurse #6 said that she was unaware that there were supposed to be fall mats in place on both sides of Resident #90's bed.

During an interview on 1/9/25 at 12:37 P.M., the Director of Clinical Operations #2 on said that it is her expectation that nursing staff follow Physician's orders. She said that when an order is in place for a bed to be in lowest position with fall mats in place when in bed, that is what should be occurring.

49880

2. Resident #73 was admitted to the facility in July 2024 with diagnoses that include personal history of suicidal ideation, schizoaffective disorder, bipolar type, personal history of adult physical and sexual abuse.

Review of the most recent Minimum Data Set (MDS) assessment, dated 10/11/24, indicated a Brief Interview for Mental Status exam score was not able to be obtained and Resident #73 was assessed by staff to have severely impaired cognition. The MDS further indicated 12-14 days of the look back period (nearly every day)

the resident had little interest or pleasure in doing things and felt tired or had little energy.

Review of Resident #73's active plan of care failed to indicate a plan of care for a diagnosis of personal history of suicidal ideation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0656 During an interview on 1/9/25 at 12:20 P.M., the Social Worker (SW) said that when a resident has a diagnosis of history of suicidal ideation a plan of care should be developed so that direct care staff are aware Level of Harm - Minimal harm or of the history, regardless of how recent or distant the suicidal ideation is. The SW said when residents are potential for actual harm admitted with this diagnosis, even if they deny suicidal ideation on admission, the process should still be followed so that their plan of care is person centered and tailored to their needs. Residents Affected - Few

During an interview on 1/9/25 at 12:47 P.M., the Director of Clinical Operations #2 said that regardless of how long ago the history of suicidal ideation was, and regardless of if the resident denies it on admission, a plan of care should be in place. She said that if it is present on admission, all staff should be evaluating the hospital discharge summary and gathering information to develop a plan of care.

36797

3. For Resident #24 the facility failed to develop a care plan for the use of antidepressant and anti-anxiety medication.

Resident #24 was admitted to the facility in November 2023 with diagnoses including dementia, depression and psychosis.

Review of the physician orders dated January 2025 indicated the following orders:

-Ativan oral tablet 1 MG (milligram). Give 1 mg by mouth at bedtime related to unspecified dementia, unspecified severity, with other behavioral disturbance.

- Trazodone HCL oral tablet 50 MG, give 25 MG by mouth at bedtime related to unspecified dementia, unspecified severity, with other behavioral disturbance.

Review of the current care plan for Resident #24 failed to indicate a focus, goals and interventions for the use of the anti anxiety medication Ativan and the antidepressant medication Trazodone.

During an interview on 1/7/25 at 2:01 P.M., Unit Manager #1 said that she assumes that care plans should be in place for the use of both anti-anxiety and antidepressant medications.

44095

4. Resident #74 was admitted to the facility in January 2023 with diagnoses including traumatic brain injury, history of falling, and muscle weakness.

Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #74 was rarely/ never understood. This MDS further indicted Resident #74 rejected care and was dependent

on staff for activities of daily living.

On 1/6/25 at 7:36 A.M., 1/7/25 at 6:39 A.M., and 1/9/25 at 6:44 A.M., the surveyor observed Resident #74 in his/her bed, the side rails were in the middle of the bed, and they were not padded.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0656 Review of Resident #74's plan of care related to activities of daily living, dated as revised 1/25/23, indicated:

Level of Harm - Minimal harm or -Bed mobility-dependent of two. potential for actual harm

Review of Resident #74's plan of care related to side rails, dated 1/25/23, indicated: Residents Affected - Few -Resident's side rails are padded to assist in skin integrity in skin integrity and limbs sliding through side.

Review of Resident #74's plan of care related to potential for skin, dated as revised 3/26/23, indicated:

-Residents side rails are padded to assist in skin integrity and limbs sliding through the side bar.

During an interview on 1/9/25 at 7:37 A.M., Certified Nursing Assistant (CNA) #2 said Resident #74 does not have padded side rails on his/her bed.

During an interview on 1/9/25 at 9:25 A.M., the Director of Clinical Operations #2 said nursing should implement the plan of care related to padding the side rails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 44095

Residents Affected - Few Based on observations, interviews, and record review the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for two Residents (#35 and #61) out of a total sample of 24 residents. Specifically,

1. For Resident #35 the facility failed to review and revise the care plan related to the oxygen flow rate for a tracheostomy (surgical incision in the neck to the windpipe to create an airway).

2. For Resident #61 the facility failed to review and revise the care plan related to protective equipment used for smoking (smoking apron).

Findings include:

Review of the facility policy titled, Care Plans, Comprehensive Person- Centered, dated as revised 1/24, indicated a comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial and functional needs is developed for each resident.

1. The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, may assist with the development of a comprehensive, care plan for each resident.

7. Evaluation of residents is ongoing and care plans are revised as information about the resident and the resident conditions change.

8. The IDT team reviews and updates the care plan when there has been a significant change in the resident's conditions, when there is a change and at least quarterly, in conjunction with the required quarterly MDS assessment.

Review of the facility policy titled, Comprehensive Assessment and the Care Delivery Process, dated as revised 8/19, indicated comprehensive assessment will be conducted to assist in developing person-centered care plans.

g. Completed assessments (baseline, comprehensive, MDS, etc.) are maintained in the resident's active

record for a minimum of up to 15 months. These assessments are used to develop, review and revise the resident's comprehensive care plan.

1. Resident #35 was admitted to the facility in October 2022 with diagnoses including anoxic brain damage, chronic respiratory failure, and tracheostomy status.

Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/24, indicated that Resident #35 was rarely/never understood. This MDS indicated Resident #35 was dependent on staff for activities of daily living. The MDS indicated Resident #35 received oxygen therapy and tracheostomy care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0657 On 1/6/25 at 7:49 A.M., and at 3:07 P.M., 1/7/25 at 6:52 A.M., and at 1:41 P.M. and on 1/8/25 at 1:06 P.M.,

the surveyor observed Resident #35 receiving oxygen at 4 liters per minute via tracheostomy mask. Level of Harm - Minimal harm or potential for actual harm Review of Resident #35's plan of care related to tracheostomy related to anoxic brain injury, dated as revised 2/14/23, indicated: Residents Affected - Few - Oxygen Settings: Tracheostomy mask at 28% humidified oxygen continuously on 2 liters, dated as revised 6/10/24.

Review of Resident #35's physician's order, dated 7/15/24, indicated:

- Administer oxygen at 4 liters per minute via tracheostomy mask continuously with 28% humidification.

Review of Resident #35's physician progress note, dated 11/1/24, indicated:

-Tracheostomy at 4 liters per minute.

During an interview on 1/7/25 at 1:42 P.M., Nurse #2 said that Resident #35 is receiving oxygen at 4 liters per minute.

During an interview on 1/9/25 at 9:01 A.M., the Director of Clinical Operations #2 said that the care plan should reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments to match the current oxygen flow rate, but that it had not been.

2. Review of the facility policy titled, Smoking- Policy Residents, dated as revised 3/24, indicated that this facility shall establish and maintain safe resident smoking practices.

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

5. The resident will be evaluated upon admission and/or when a resident chooses to smoke, to determine if

the resident's ability to smoke safely.

6. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.

7. Any smoking-related concerns will be noted in the resident care plan.

9. Resident who are supervised for smoking will be monitored by a staff member or designee during the allowed smoking times

Resident #61 was admitted to the facility in September 2023 with diagnoses including diabetes, depression, and failure to thrive.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0657 Review of the most recent Minimum Data Set (MDS) assessment, dated 12/20/24, indicated that Resident #61 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 13 out of 15. Level of Harm - Minimal harm or This MDS further indicated Resident #61 required assistance with activities of daily living. potential for actual harm

Review of Resident #61's NSH Smoking Evaluation, dated 8/31/24 and 9/25/24, indicated: Residents Affected - Few -Resident is safety to smoke with supervision and protective smoking equipment.

Review of Resident #61's NSH Smoking Evaluation, dated 12/5/24, indicated:

-Resident is able to smoke with supervision without protective smoking equipment.

Review of Resident #61's current plan of care related to smoking, dated as revised 12/5/24, indicated:

-Supervised, Apron while smoking, initiated on 9/26/23.

During an interview on 1/7/25 at 11:43 A.M., Resident #61 said he/she smokes three times a day. Resident #61 said he/she does not wear a smoking apron and never has worn an apron.

On 1/8/25 between 1:26 P.M., through 1:34 P.M., the surveyor observed Resident #61 outside smoking without a smoking apron.

During an interview on 1/8/25 at 3:40 P.M., Activities Assistant #1 said Resident #61 does not use a smoking apron and he/she has never used a smoking apron.

During an interview on 1/8/25 at 3:42 P.M., Activities Assistant #2 said Resident #61 does not use a smoking apron and he/she has never used a smoking apron.

During an interview on 1/9/25 at 9:30 A.M., the Director of Clinical Operations #2 said Resident #61's smoking care plan should reflect the most recent assessment completed by the IDT team.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

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

Level of Harm - Minimal harm or 36797 potential for actual harm Based on observation, record review and interview, the facility failed to meet professional standards of Residents Affected - Some practice for three Residents (#14, #35 and #74) out of a total of sample of 24 residents. Specifically:

1. For Resident #14 the facility failed to follow-up on rising abnormal PSA (prostate surface antigen). A potential indicator of cancer levels.

2. For Resident #35 the facility failed to ensure nursing clarified a physician's order for medications that were ordered orally and Resident #35 received medications via g-tube (tube inserted into the stomach).

3. For Resident #74 the facility failed to ensure nursing clarified a physician's order for g-tube flushes (two different frequencies in one order).

Findings include:

1. Resident #14 was admitted to the facility in October 2022 with diagnoses including schizophrenia, stroke and diabetes.

Review of the facility document titled Lab Results Report, dated 6/18/24, indicated a PSA level of 12.280. (Normal is below 5.4)

Review of the facility document titled Consultation/Clinic Referral Urology, dated 10/16/24, indicated Resident #14 seems to have obstructive symptoms. The report further indicated for Resident #14 to have a PSA level obtained and for Resident #14 to return in one month.

Review of the facility document titled Lab Results Report, dated 10/17/24, indicated a PSA level of 15.36.

Review of the clinical progress notes indicated the following:

10/3/24- Elevated PSA await urology follow-up

10/16/24- Out for urology appointment. Resident returned from urology appointment, labs PSA free and total, NP (nurse practitioner) aware.

10/17/24-Lab result in PSA result, CH 15.36, NP aware, no new order.

10/24/24- Had recent PSA testing which was elevated at 15.

11/7/24- Had recent PSA testing which was elevated at 15. Urology consult scheduled.

11/20/24- Attempted to schedule urology consult. (Hospital) social worker will call back with appointment in 5 to 7 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0658 11/21/24- Had recent PSA testing which was elevated at 15.

Level of Harm - Minimal harm or 12/5/24- Had recent PSA testing which was elevated at 15. potential for actual harm 12/12/24- Had recent PSA testing which was elevated at 15. Residents Affected - Some 12/13/24- Had recent PSA testing which was elevated at 15.

12/24/24- Had recent PSA testing which was elevated at 15.

12/26/24- Had recent PSA testing which was elevated at 15.

12/29/24- Urology consult scheduled, await follow-up. (The appointment was not scheduled).

12/31/24- Had recent PSA testing which was elevated at 15.

1/1/24- Had recent PSA testing which was elevated at 15.

1/7/24-clarification for urology consult that was pending. Urology consult scheduled for 11/14/24, was canceled due to lack of communication with facility; Resident requiring labs 2 weeks prior to appointment. Appointment now re-scheduled.

During an interview on 1/7/25 at 11:07 A.M., Unit Manager #1 said that she would have expected that a follow-up appointment would have been scheduled. Unit Manager #1 then said that treatment options regarding the PSA level of 15 should have been discussed with Resident #14's responsible party.

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2. Review of the facility policy titled, Administering Medications, dated as revised 9/24, indicated that medications are administered in a safe and timely manner, and as prescribed.

b. Medications are administered in accordance with prescriber orders, including any required time frame.

e. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Resident #35 was admitted to the facility in October 2022 with diagnoses including anoxic brain damage, chronic respiratory failure, and tracheostomy status.

Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/24, indicated that Resident #35 was rarely/never understood and required a feeding tube.

Review of Resident #35's current physician's orders, with a start date of 8/23/23, indicated:

-NPO (nothing by mouth)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0658 Review of Resident #35's active physician's orders on 1/6/25, indicated the following were ordered to be administered by mouth: Level of Harm - Minimal harm or potential for actual harm -aspirin 81 milligrams (mg) by mouth daily, initiated on 11/23/24.

Residents Affected - Some -atorvastatin 40 mg by mouth at bedtime, initiated on 11/14/24.

-fenofibrate 145 mg by mouth at bedtime, initiated on 11/14/24.

During an interview on 1/8/25 at 1:03 P.M., Nurse #3 said Resident #35 takes his/her medications via g-tube. Nurse #3 said she administers medications in accordance with the physician's orders. Nurse #3 reviewed Resident #3's physician's order for aspirin and Nurse #3 said that she administered the medication by g-tube today.

During an interview on 1/9/25 at 9:00 A.M., the Director of Clinical Operations #2 said medications should be administered as ordered and that nursing should have clarified Resident #35's orders and administered medications via g-tube.

3. Review of the facility policy titled, Enteral Nutrition, dated as revised 9/18, indicated that enteral nutrition is provided to residents when deemed to be medically necessary and consented by the resident or durable power of attorney (DPOA) for healthcare using evidence-based practice and procedures to minimize complications and maintain or improve nutritional status to the extent possible.

Gastrostomy tube (G-tube) is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. The most common type is a percutaneous endoscopic gastrostomy (PEG) tube.

9. When the resident is fed by tube:

iv. flushing with water at appropriate intervals.

Resident #74 was admitted to the facility in January 2023 with diagnoses including traumatic brain injury, history of falling, and muscle weakness.

Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #74 was rarely/ never understood. The MDS further indicated that Resident #74 rejected care, was dependent on staff for activities of daily living and had a feeding tube.

Review of Resident #74's nutrition progress note, dated 9/5/24, indicated:

-Adjust water flushes to 250 milliliters (mL) four times daily.

Review of Resident #74's current physician's order, with a start date of 10/13/24, indicated:

-Enteral Feed, every 4 hours 250 milliliters (mL) flush 4 times daily. Scheduled every 4 hours at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. (6 times daily)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0658 Review of Resident #74's Medication Administration Record (MAR), dated January 2025, indicated nursing administered the physician's order and documented by nursing as administered every 4 hours (6 times daily). Level of Harm - Minimal harm or potential for actual harm During an interview on 1/8/25 at 12:52 P.M., Nurse #4 said Resident #74's feeding tube is flushed according to the physician's orders. Residents Affected - Some

During an interview on 1/9/25 at 9:52 A.M., the Dietitian said that Resident #74 should receive water flushes of 250 mL four times daily.

During an interview on 1/9/25 9:11 A.M., the Director of Clinical Operations #2 reviewed Resident #74's flush orders in the electronic health record and said that the order was not clear and should have been clarified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 41105 potential for actual harm Based on observation, record review and interview the facility failed to ensure assistance with Activities of Residents Affected - Some Daily Living (ADLs) were provided to three Residents (#23, #5, and #7) out of a total sample of 24 residents. Specifically:

1. For Resident #23 the facility failed to ensure assistance with bed mobility and dining was provided as needed.

2. For Resident #5 the facility failed to ensure assistance with positioning and feeding was provided as needed.

3. For Resident #7 the facility failed to ensure assistance with grooming was provided as needed.

Findings include:

Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, dated as revised 11/2024, indicated the following:

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

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

b. Mobility (transfers and ambulation, including walking);

c. Elimination (toileting);

d. Dining (meals and snacks); and

e. Communication (speech, language, and any functional communication systems).

1. Resident #23 was admitted to the facility in November 2022 and has diagnoses that include Alzheimer's dementia and anxiety disorder.

Review of the most recent Minimum Data Set (MDS) assessment, dated 11/1/24, indicated that Resident #23 was assessed by staff to have severely impaired cognition. The MDS further indicated that Resident #23 is dependent on staff for eating and bed mobility.

Review of the current ADL care plan, last revised 11/19/24, indicates the following:

-Eating: assist to dependent.

-Bed mobility-Ext (extensive) to Dep (dependent)-2 assist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 -ADL performance ability fluctuates due to a decline in cognitive status and episodes of fatigue and weakness. Level of Harm - Minimal harm or potential for actual harm Review of the Functional Abilities and Goals Assessment, dated 11/1/24, indicated Resident #23 is dependent on staff for eating and mobility. Residents Affected - Some

Review of the Medical Nutrition Therapy Assessment, dated 10/30/24, indicated need for assistance w/eating (sic).

On 1/6/25 at 8:52 A.M., the surveyor observed Resident #23 laying flat in bed. A staff person delivered breakfast to the Resident's room, placed the tray on a tray table out of reach and exited the room to continue passing trays to other residents. The surveyor continued to make the following observation:

-At 8:54 A.M., the surveyor entered Resident #23's room and observed Resident #23 laying awake in a flat bed, awake, able to see the breakfast tray, however unable to reach it.

On 1/6/25 at 12:21 P.M., the surveyor observed Resident #23 in a recliner chair in the unit dining room. There was a lunch plate directly in front of him/her and Resident #23 was eating mac and cheese with his/her hands. The resident then picked up a cup of milk, looked at it then placed it in the middle of his/her plate on top of the mac and cheese. The surveyor continued to make the following observations:

-At 12:25 P.M., Resident #23 sat with the cup of milk in his/her food and watched other residents eating and

a Nurse walked past him/her and out of the dining room without offering any assist with the meal.

-At 12:31 P.M., a Certified Nursing Assistant (CNA) asked Resident #23 are you not going to eat, then without offering assistance or waiting for a response sat down with her back to Resident #23 and began assisting a peer with their meal.

On 1/7/25 at 12:14 P.M., the surveyor observed Resident #23 in a recliner chair in the unit dining room. A CNA set up lunch on the tray table in front of Resident #23 and walked away without offering assist with the meal. The surveyor continued to make the following observations:

-At 12:19 P.M., Resident #23 started crying, and Nurse #1 walked over, told Resident #677 start feeding yourself and I will help you finish, I have to finish helping someone else first. Nurse #1 did not assist the Resident with the meal in front of him/her.

During an interview on 1/10/25 at 8:55 A.M., with Resident #23's CNA #1 she said that Resident #23 is totally dependent for care, including with feeding.

During an interview on 1/10/25 at 9:37 A.M., with the Director of Clinical Operations #2 she said meal trays should remain in the cart until staff are ready to sit down and assist a resident who is dependent for feeding.

She said that it is her expectation that dependent residents be fed their meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 2. Resident #5 was admitted to the facility in November 2022 and has diagnoses that include dysphagia (difficulty chewing and swallowing) and contracture of the left and right hand. Level of Harm - Minimal harm or potential for actual harm Review of the most recent Minimum Data Set (MDS) assessment, dated 11/1/24, indicated staff did not assess Resident #5's cognition however that he/she is rarely or never understood. The MDS further Residents Affected - Some indicated that Resident #5 has no behavior of rejecting care, has impairment on both sides of upper extremities, and requires supervision or touching assistance with eating.

Review of the current Nutrition care plan indicates the following:

-NUTRITION: at risk for decline r/t (related to) limited mobility, difficulty feeding self, dysphagia, h/o (history of) dysphagia, hypertensive HF (heart failure), hypothyroidism, etoh (Alcohol) dependence.

Review of the Medical Nutrition Therapy Assessment, dated 10/30/24, indicated at risk for decline r/t limited mobility, difficulty feeding self, dysphagia.

Review of the current Activities of Daily Living care plan indicates: Resident has ADL self-care deficit as evidenced by: needs assistance with all ADL care.

Review of the Functional Abilities Assessment, dated 11/19/24, indicates that Resident #5 requires supervision or touching assistance with meals.

On 1/7/25 at 8:08 A.M., a Certified Nursing Assistant (CNA) delivered a breakfast tray to Resident #5 who was seated in a recliner chair, tucked in a corner of the room out of eyesight of all others. The CNA set up

the tray and walked away offering no supervision or assistance with the meal. The surveyor continued to make the following observations:

-At 8:10 A.M., Resident #5 attempted to use a two-handle cup to drinking orange juice, however his/her hands were shaking, and Resident #5 was unsuccessful at drinking the beverage, but rather it spilled on his/her chest.

-At 8:11 A.M., Resident #5 picked up another liquid, but his/her hands were shaking so much the liquid spilled all over the food on the tray.

-By 8:15 A.M., Resident #5 had made no attempts to self-feed. The surveyor approached the Resident and asked how the meal was. Resident #5 appeared confused and smiled and nodded at the surveyor.

On 1/7/25 at 12:12 P.M., a CNA set up Resident #5's lunch in front of him/her then walked away to continue passing meals to other residents without positioning Resident #5 in an upright position in the recliner and without offering assistance with the meal. Resident #5's recliner back was at a 45-degree angle and he/she had slid down in the chair, unable to reach the food. The surveyor continued to make the following observations:

-At 12:16 P.M., Resident #5 said to Nurse #1 can you pick me up a little as he/she had slid down in the recliner chair and poorly positioned to reach the food. Nurse #1 and a CNA boosted Resident #5 then walked away offering no assist with the meal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 -By 12:19 P.M., no staff had offered touching assistance with the meal and Resident #5 had made no attempts to self-feed. Level of Harm - Minimal harm or potential for actual harm On 1/10/25 at 8:35 A.M., Resident #5 was observed in a recliner chair in the dining room with the head of the recliner at a 45-degree angle. Nurse #1 set up Resident #5's meal on a tray table in front of him/her and Residents Affected - Some walked away without positioning him/her upright or offering assistance with the meal. Resident #5 shakily reached for his/her double handled cup and as he/she tried to drink the beverage it spilled on his/her chest. No staff were present in the room to supervise or assist the resident.

During an interview on 1/10/25 at 10:14 A.M., with Certified Nursing Assistant (CNA) #3 she said that Resident #5 requires total assistance with care and when he/she cannot feed him/herself we help him/her. CNA #3 said that whenever a resident is struggling to feed themselves, assistance should be offered.

During an interview on 1/10/25 at 10:26 A.M., with Nurse #6 she said that Resident #5 shakes when he/she eats which is why he/she has special cups and utensils. Nurse #6 said that Resident #5's chair should be put upright for meals, that staff should always be present in the room for meals and if they notice Resident #5 is struggling or spilling they should assist him/her.

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3. Resident #7 was admitted to the facility in July 2024 with diagnoses including dementia, tracheostomy, diabetes, and seizures.

Review of the most recent Minimum Data Set (MDS) assessment, dated 10/4/24, indicated that Resident #7 was comatose. The MDS further indicated Resident #7 was dependent on staff for activities of daily living.

On 1/6/25 at 7:45 A.M., and at 3:08 P.M., 1/7/25 at 6:52 A.M., and at 1:10 P.M., the surveyor observed Resident #7 in his/her bed he/she had facial hair around 5 millimeters in length.

Review of Resident #7's plan of care related to activities of daily living, dated as revised 9/11/24, indicated:

- Grooming, dependent two assists.

During an interview on 1/7/25 at 1:37 P.M., Certified Nurse Assistant (CNA) #1 said Resident #7 should be shaved once a week and she needs the nurse to assist with shaving needs.

During an interview on 1/7/25 at 1:56 P.M., Nurse #2 said CNAs should shave Resident #7 during care. Nurse #2 said that Resident #7 has facial hair that is long, and the facial hair should have been shaved

during care.

During an interview on 1/9/25 at 9:06 A.M., the Director of Clinical Operations #2 said grooming such as shaving should be provided routinely during care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0685 Assist a resident in gaining access to vision and hearing services.

Level of Harm - Minimal harm or 41105 potential for actual harm Based on observation, record review and interview the facility failed to ensure vision services were provided Residents Affected - Few for one Resident (#6) out of a total sample of 24 residents. Specifically, the facility failed to ensure arrangements were made to repair eyeglasses for Resident #6.

Findings include:

Resident #6 was admitted to the facility in March 2022 and has diagnoses that include absolute glaucoma and artificial left eye.

Review of Resident #6's most recent Minimum Data Set (MDS) assessment, dated 12/6/24, indicates that Resident #6 has moderately impaired vision and wears corrective lenses. On the Brief Interview for Mental Status exam Resident #6 scored a 6 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #6 has no behavior of rejecting care.

Review of the current communication care plan for Resident #6 includes the following intervention:

-Ensure hearing amplifier aid/glasses or other assistive devices are in place, start date 4/19/22.

Review of the clinical progress notes indicates a note written by nursing, dated 8/25/24:

-Social work needs to buy resident a new pair of glass (sic). Resident was wearing a broken glass (sic) which has potential risk to damage his/her R (right) eye which is his/her only functioned (sic) eye.

Review of the most recent Social Service Evaluation, dated 12/17/24, indicated Resident #6's vision was adequate and made no mention of the missing eyeglasses.

Review of Resident #6's most recent Nursing Evaluation, dated 12/1/24, indicates that Resident #6 has moderately impaired vision, wears corrective lenses, and wears a left prosthetic eye.

Review of the Physician's Encounter progress note, dated 12/27/24, indicated that the Resident was recently seen at the hospital due to a bleed of his/her prosthetic eye and would need to follow-up with ophthalmology. There was no mention of Resident #6's eyeglasses being in disrepair.

Review of the clinical progress notes failed to indicate a referral was made to have the eyeglasses repaired.

During an observation and interview on 1/6/25 at 8:14 A.M., Resident #6 was observed in bed wearing broken, smudged glasses. Resident #6 said the glasses need to be cleaned and that they broke a long time ago, but no one has assisted him/her to get them repaired. The right-side arm of the glasses is broken off.

On 1/7/25 at 11:43 A.M., Resident #6 was observed in bed wearing broken glasses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0685 On 1/10/25 at 7:58 A.M., Resident #6 was observed in bed, holding his/her broken glasses.

Level of Harm - Minimal harm or During an interview on 1/10/25 at 7:58 A.M., with Resident #6's Certified Nursing Assistant (CNA) #3 she potential for actual harm said that she was aware that Resident #6's glasses are broken and added they have been broken for some time now. CNA #3 said that she does not know what's being done about the broken glasses. Residents Affected - Few

During an interview on 1/10/25 at 8:52 A.M., with Resident #6's Social Worker (SW) she said that it is the expectation that if a resident breaks their eyeglasses that a referral be made to the contracted ophthalmology services to arrange a visit with the eye doctor to facilitate the repair of the glasses. She said that she was unaware that Resident #6's glasses were broken.

During a follow-up interview on 1/10/25 at 10:08 A.M., the SW said that she learned that the Physician's Assistant saw Resident #6 on 12/16/24 regarding the broken glasses and that Resident #6 will be seen by

the eye doctor in February to address the issue. SW #1 said that there is no information in the record to indicate what occurred between August and December 2024 to address the broken eyeglasses.

During an interview on 1/10/25 at 9:45 A.M., with the Director of Clinical Operations #2 she said that when a resident breaks their glasses, the ophthalmologist should be contacted to issue a new pair of glasses, or a plan determined with the family about how they will be replaced. She said that the plan should be documented in the record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

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

Level of Harm - Minimal harm or 44095 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure nursing implemented Residents Affected - Few interventions for pressure ulcer care for one Resident (#61) out of a total sample of 24 Residents. Specifically for Resident #61 the facility failed to ensure that nursing implemented physician's ordered Prevalon boots and failed to consistently elevate his/her heels off the bed.

Findings include:

Review of the facility policy titled, Prevention and management of Pressure Ulcers/ Injuries, dated as revised 11/24, indicated the purpose of this policy is to ensure a resident receives care consistent with professional standard of practice to prevent pressure ulcers and/or residents with pressure ulcer receive necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing.

-Definitions:

Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over

a bony prominence or related to a medical or other device.

*Stage 3 Pressure Injury: Full-thickness tissue loss

-The Stage 3 PI appears as full-thickness loss of skin and tissue, in which subcutaneous fat may be visible in

the ulcer and granulation tissue and epibole (rolled wound edges) are often present.

- Slough and/or eschar may be visible but does not obscure the depth of tissue loss.

- The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds.

- Undermining and tunneling may occur.

- Fascia, muscle, tendon, ligament, cartilage and/or bone are NOT exposed.

- If slough or eschar obscures the wound bed, it is an Unstageable PI.

*Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed

-The Stage 4 Pl appears as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer.

- Slough and/or eschar may be visible on some parts of the wound bed.

- Epibole (rolled edges), Undermining and/or Tunneling often occur.

- Depth varies by anatomical location.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0686 *Risk Assessment

Level of Harm - Minimal harm or 5. Develop the resident-centered care plan and interventions based on the risk factors identified, the potential for actual harm condition of the skin, the resident's overall clinical condition.

Residents Affected - Few Resident #61 was admitted to the facility in September 2023 with diagnoses including diabetes, depression, and failure to thrive.

Review of the most recent Minimum Data Set (MDS) assessment, dated 12/20/24, indicated that Resident #61 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 13 out of 15.

The MDS further indicated Resident #61 required assistance with activities of daily living, has one Stage 3 pressure ulcer and two Stage 4 pressure ulcers.

Review of Resident #61's plan of care related to activities of daily living, dated as revised 11/1/23, indicated:

-bed mobility: limited to extensive assistance of one, revised 10/3/23.

Review of Resident #61's current physician's order, with a start date of 8/31/24, indicated:

-Prevalon boots and elevate lower legs to reduce pressure.

Review of Resident #61's plan of care related to actual alteration in skin integrity, dated as revised 1/3/25, indicated:

-Consult and treatment by Certified Wound Physician, dated as initiated 9/26/23.

-Heels, offloaded when in bed, dated as initiated 11/19/24.

Review of the physician's order, dated 12/18/24, indicated:

-Right Lateral Heel, Stage 3.

Review of Resident #61's physician's order, dated 1/1/25, indicated:

-Pressure wound right lateral foot.

On 1/6/25 at 8:13 A.M., 1/6/25 at 9:02 A.M., 1/6/25 at 12:39 P.M., 1/6/25 at 3:04 P.M., 1/6/25 at 4:30 P.M., 1/7/25 at 6:50 A.M., 1/7/25 a 11:43 A.M., 1/9/25 at 6:47 A.M., and 1/9/25 at 7:37 A.M., the surveyor observed Resident #61's right heel directly on the bed extender and not elevated. There were no Prevalon boots as ordered by the physician.

During an interview on 1/7/25 at 1:10 P.M., Resident #61 said he/she was not provided with any boots by the facility.

During an interview on 1/9/25 at 2:00 P.M., Certified Nursing Assistant (CNA) #2 said Resident #61 does not wear boots, and Resident #61 has wounds on his/her feet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0686 During an interview on 1/9/25 at 9:33 A.M., the Director of Clinical Operations #2 said nursing should implement care plan interventions and physician's orders to promote wound healing. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 44095

Residents Affected - Few Based on observation, interview, and record review, the facility failed to consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for one Resident (#35) out of a total sample of 24 residents.

Specifically, the facility failed to ensure staff obtained physician's orders for bilateral hand splints (a device to properly position and protect hand joints) use based on the Occupational Therapist's recommendation.

Findings include:

Review of the facility policy titled, Care Plans, Comprehensive Person- Centered, dated as revised 1/24, indicated a comprehensive, person- centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial and functional needs is developed for each resident.

1. The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, may assist with the development of a comprehensive, care plan for each resident.

2. The care plan interventions are derived from information gathered as part of the comprehensive assessment.

3. The resident comprehensive care plan will identify problem areas and their causes as warranted and develop interventions that are targeted and meaningful to the resident.

Resident #35 was admitted to the facility in October 2022 with diagnoses including anoxic brain damage, chronic respiratory failure, and tracheostomy status.

Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/24, indicated that Resident #35 was rarely/never understood. This MDS further indicated Resident #35 was dependent on staff for activities of daily living and Resident #35 had functional limitation in range of monition on both sides of the upper extremities and lower extremities.

On 1/6/25 at 7:49 A.M., and at 3:07 P.M., 1/7/25 at 6:52 A.M., and at 1:41 P.M. and on 1/8/25 at 1:06 P.M.,

the surveyor observed Resident #35 in his/her bed wearing bilateral hand splints.

Review of Resident #35's physician's order, dated 12/31/24, indicated:

-Occupational Therapy Services discontinued on 12/31/24.

Review of Resident #35's Occupational Therapy (OT) Discharge Summary, dated 12/31/24, indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 -Discharge Recommendations: It is recommended that bilateral upper extremities orthoses to be donned every day for as long as possible with no signs of discomfort/redness. Orthotics should be checked at every Level of Harm - Minimal harm or shift change to ensure skin is intact. potential for actual harm

Review of Resident #35's physician's orders on 1/6/25, failed to include documentation to support a splint Residents Affected - Few wearing schedule.

Review of Resident #35's plan of care on 1/6/25, failed to include documentation to support a splint wearing schedule.

During an interview on 1/7/25 at 1:38 P.M., Certified Nurse Assistant (CNA) #1 said that splits should be removed while providing care and she was not sure how long Resident #35 should wear his/her hand splints.

During an interview on 1/7/25 at 1:41 P.M., Nurse #2 said she was not sure when Resident #35 was supposed to wear his/her hand splints. Nurse #2 said she thought that Resident #35 must have his/her splints applied on the evening and night shifts. Nurse #2 reviewed Resident #35's medical record and said

she did not have any instructions for splint use or care, but that she should.

During an interview on 1/8/25 at 1:06 P.M., Nurse #3 said that Resident #35 has hand splints on and Nurse #3 said that splint care is provided based on the physician's orders. Nurse #3 reviewed the electronic health

record and Nurse #3 said she was not sure what Resident #35's splint wearing schedule was.

During an interview on 1/8/25 at 2:49 P.M., the Director of Clinical Operations #2 said that splint use should be care planned to include a schedule of when to wear and when to remove the hand splints. As well, she said that there were no orders for splints in the electronic health record but that there should be.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 49880 potential for actual harm Based on record review and interview, the facility failed to maintain acceptable parameters of nutritional Residents Affected - Few status for one Resident (#88) out of a total sample of 24 residents. Specifically, for Resident #88 the facility failed to obtain weights as ordered and identify and address potential significant weight changes by not reviewing post dialysis weights and reweighing the resident in a timely manner to confirm a significant weight change.

Findings Include:

Review of facility policy titled Weight Management, dated as revised 4/4/19 indicated the following:

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

-All residents with significant weight changes will have verification of weight measurement for accuracy and documentation purposes.

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

Resident #88 was admitted to the facility in November 2024 with diagnoses that include end stage renal disease and dependence on renal dialysis.

Review of Resident #88's most recent Minimum Data Set (MDS) Assessment, dated 11/26/24, indicated a Brief Interview for Mental Status exam score of 15 out of 15, indicating intact cognition.

Review of Resident #88's active care plan indicated the following:

-A nutrition care plan that indicated the Resident is underweight related to suspected poor PO (oral) intake as exhibited by low BMI (body mass index)

Review of Resident #88's current physician's orders indicated the following order:

-Check weight once weekly on Tuesdays in the morning, dated 12/17/24.

Review of Resident #88's electronic medical record indicated the following weights:

-11/20/24 100.6 pounds (lbs.)

The record failed to indicate any further weights were obtained.

Review of the Nutrition Assessment, dated 11/21/24, indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 -The need for increased nutrient needs due to the resident being underweight.

Level of Harm - Minimal harm or -Noted a current weight of 100.6 with observed clavicle and temporal wasting. potential for actual harm

Review of Resident #88's Dialysis Communication Book indicated the following documented weights from Residents Affected - Few the dialysis center:

12/9/24 communication sheet indicated a pre dialysis weight of 62.7 kilograms (kg) or 137.94 lbs., and a post dialysis weight of 60.4 kg or 132.88 lbs.

12/27/24 communication sheet indicated a pre dialysis weight of 61.3 kg or 134.86 lbs., and a post dialysis weight of 59.7 kg or 131.34 lbs.

12/31/24 communication sheet indicated a pre dialysis weight of 63.1 kg or 138.82 lbs. but did not indicate a post dialysis weight.

1/8/24 dialysis communication sheet indicated a post dialysis weight of 50.3 kg or 110.66 lbs.

-On 11/20/24, the Resident weighed 100.6 lbs., and on 12/9/24, the Resident weighed 132.88 lbs. which is a 32.09 % gain in 19 days.

-On 12/31/24, the Resident weighed 138.82 lbs., and on 1/8/25, the Resident weighed 110.66 pounds which is a -20.29 % loss in 8 days.

Review of the medical record failed to indicate that post dialysis weights were reviewed and evaluated for potential significant gain or loss.

Review of the December 2024 Medication Administration Record (MAR) indicated the following:

-Failed to indicate that a weight was obtained on 12/24/24 as indicated and was signed as obtained on 12/31/24 but was not documented in the medical record.

Review of the January 2025 MAR indicated the following:

-Indicated the Resident refused to be weighed on 1/7/24 and a progress note that indicated, patient refused to take weight, prefers to do it at 8 am (sic).

Review of Resident #88's medical record failed to indicate the plan of care was adjusted to an 8:00 A.M. weight or that any follow up weight was obtained after the 1/7/24 refusal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 1/9/25 at 9:48 A.M., the Dietitian said Resident #88 is a newer resident in the facility.

The Dietitian reviewed the electronic medical record and said only one weight had been recorded for the Level of Harm - Minimal harm or Resident, but there should be more by this time. She said all weights should be documented in the electronic potential for actual harm medical record. She said that if a resident is refusing to be weighed, she would expect to be notified, but she was not aware that Resident #88 had been refusing some weights. The Dietitian said when a resident Residents Affected - Few refuses to be weighed the staff should reoffer and continue to attempt to obtain the weight. She said she has not reviewed the dialysis communication book and said that if there are weights in there, she is not aware of them. She said that she has not had communication with the Registered Dietitian at the dialysis center.

During an interview on 1/9/25 at 11:10 A.M., Nurse #7 said that the nurses are responsible for checking for post dialysis weights in the dialysis communication book for changes and checking for recommendations regarding medication changes. She said she was not sure if Resident #88 had any changes or irregularities

in his/her weight. She said that the weights or vital signs documented at dialysis are not entered into the electronic medical record. Nurse #7 also said that she is not sure what the process is if a resident refuses a weight but if there was a concern with the weight, she would let the provider know the resident had a gain or loss.

During an interview on 1/9/25 at 12:37 P.M., Director of Clinical Operations #2 said upon return from dialysis, nurses should be checking the dialysis communication book for the post dialysis weights and vital signs, and those readings should be entered into the electronic medical record. She said she would expect that any weights obtained in the center or at dialysis are evaluated and compared to previous weights. Further, she said at the center weights should be obtained as ordered, and if the resident is refusing a provider should be notified and it should be added to the resident's plan of care. She also said that the post dialysis weights in Resident #88's communication book should have been evaluated and assessed for a potential significant change, but they were not.

During a follow up interview on 1/9/25 at 1:17 P.M., the Dietitian said that she reviewed the weights in Resident #88's dialysis communication book and that the significant change in the weight noted on 12/9/24 should have been evaluated and addressed for a potential significant change, but was not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

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

Level of Harm - Minimal harm or 44095 potential for actual harm Based on observations, interview, and record review, the facility failed to ensure that respiratory care and Residents Affected - Few services consistent with professional standards of practice, were provided for one Resident (#26), out of a total sample of 24 Residents. Specifically for Resident #26 the facility failed to ensure nursing a.) consistently set his/her oxygen flow rate as ordered by the physician and b.) nursing changed nebulizer machine tubing as ordered by the physician.

Findings include:

Resident #26 was admitted to the facility in October 2022 with diagnoses including emphysema, chronic obstructive pulmonary disease (COPD), and anxiety.

Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/24, indicated that Resident #26 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS further indicated Resident #26 required assistance with activities of daily living.

a.) Review of the policy, Oxygen Administration, dated as revised 1/24, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration.

Preparation

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

On 1/6/25 at 7:40 A.M., and at 4:00 P.M., 1/8/25 at 3:53 P.M., and 1/9/24 at 7:45 A.M., the surveyor observed Resident #26 receiving oxygen via nasal cannula at 3 liters per minute.

Review of Resident #26's physician's progress note, dated 11/1/24, indicated Resident has a history of severe COPD with chronic oxygen use at 2 liters per minute.

Review of Resident #26's current physician's order, with a start date of 11/11/23, indicated:

-Obtain oxygen saturation every shift and administer oxygen at 2 liters per minute.

Review of Resident #26's plan of care related to respiratory status, dated as revised 11/21/24, indicated:

-Oxygen settings: oxygen via nasal cannula as ordered.

During an interview on 1/6/25 at 3:00 P.M., Nurse #5 said that Resident #26 receives oxygen based on the physician's order.

During an interview on 1/9/25 at 8:56 A.M., the Director of Clinical Operations #2 said oxygen settings should be set according to the physician's order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0695 b.) During an interview on 1/6/25 at 8:08 A.M., Resident #26 said I think I have pneumonia (infection of the lungs), I have not been feeling good all weekend, they have been giving me nebulizer treatments and I don't Level of Harm - Minimal harm or think the nebulizer is working because the mist wasn't coming up The surveyor observed the nebulizer tubing potential for actual harm dated as 12/24/24, and there was still a clear liquid in the cup (part that holds the liquid medicine).

Residents Affected - Few On 1/6/25 at 9:04 A.M., the surveyor observed Resident #26 receiving a nebulizer treatment.

Review of Resident #26's physician's order, dated 2/28/24, indicated:

-Change nebulizer and oxygen tubing and bottle weekly. Initial tubing at the time of the change.

Review of Resident #26's Treatment Administration Record (TAR), dated January 2025, indicated on 1/1/25 nursing did not change the tubing as ordered and coded the record as sleeping.

During an interview on 1/6/25 at 3:00 P.M., Nurse #5 said that Resident #26 was administered a nebulizer treatment based on the physician's order.

During an interview on 1/7/25 at 1:31 P.M., the Director of Clinical Operations #2 said nebulizer changes are completed based on the physician's orders and the nurse should not have coded the tubing change as sleeping and should have changed the nebulizer tubing as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 41105 potential for actual harm Based on record review and interview the facility failed to ensure a care plan was developed for Trauma Residents Affected - Few Informed Care, with resident specific triggers and interventions, for three Residents (#2, #73, and #78) out of

a total sample of 24 residents.

Findings include:

The facility policy titled Trauma Informed Care, dates as revised 10/19, indicated the following:

Preparation:

1. Staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder

in the context of the healthcare setting.

2. Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization.

3. Staff are guided in evidence-based organizational and interpersonal strategies that support trauma informed care.

General guidelines:

1. The facility supports a culture of emotional well-being and physical safety for staff, residents, and visitors.

2. Trauma-informed care is culturally sensitive, and person centered

3. Caregivers are taught strategies to help eliminate, mitigate, or sensitively address a residents' triggers.

1. Resident #2 was admitted to the facility in June 2024 and has diagnoses that include Adult Sexual Abuse and Dementia.

Review of the most recent Minimum Data Set (MDS) assessment, dated 12/20/24, indicated that on the Brief

Interview for Mental Status exam Resident #2 scored a 12 out of a possible 15, indicating moderately impaired cognition.

Review of the record failed to indicate a trauma assessment had been completed.

Review of the record failed to indicate a trauma care plan was in place.

Review of the hospital discharge paperwork provided to the facility in June 2024 indicated a new diagnosis of Adult Sexual Abuse due to the potential rape of Resident #2 at the prior facility he/she resided in.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 During an interview on 1/9/25 at 12:20 P.M., with the facility Social Worker (SW) she said that a

Level of Harm - Minimal harm or a trauma assessment and a trauma care plan should have been developed for Resident #2. The SW said potential for actual harm that it is the expectation that the SW follows up with the Resident, makes sure staff is aware of the situation and educate the staff regarding potential triggers for re-traumatization. Residents Affected - Few

During an interview on 1/9/25 at 12:47 P.M., with the Director of Clinical Operations #2 she said that when a Resident admits to the facility with a recent rape allegation, that the SW should follow up with the resident, assess the resident and develop a trauma care plan with resident specific interventions and triggers.

49880

2. Resident #73 was admitted to the facility in July 2024 with diagnoses that include personal history of suicidal ideation, schizoaffective disorder, bipolar type, personal history of adult physical and sexual abuse

Review of the most recent Minimum Data Set (MDS) Assessment, dated 10/11/24, indicated a Brief Interview for Mental Status exam score was not able to be obtained and Resident #73 was assessed by staff to have severely impaired cognition. The MDS further indicated 12-14 days of the look back period (nearly every day)

the resident had little interest or pleasure in doing things and felt tired or had little energy.

Review of Resident #73's medical record failed to indicate a trauma assessment had been completed.

Review of Resident #73's active plan of care failed to indicate a trauma care plan was in place.

During an interview on 1/9/25 at 12:20 P.M. Social Worker #1 said that a diagnosis of adult physical and sexual abuse would warrant a trauma assessment to be completed and a care plan be developed. She said social services would make follow up visits with the resident and make sure that everyone is aware of the trauma and potential triggers. She said a resident with this diagnosis should have a trauma care plan in place, should be referred to psych services and ensure that the physician is aware of the diagnosis and trauma.

During an interview on 1/9/25 at 12:47 A.M., Director of Clinical Operations #2 said that with a history of physical and or sexual abuse a trauma assessment and care plan should be completed. Staff should review

the hospital discharge summary to gather all information when the resident is admitted to the facility.

36797

3. Resident #78 was admitted to the facility in December 2024 with diagnoses that include assault by unspecified means, post traumatic stress disorder (PTSD) and anxiety disorder.

Review of the most recent Minimum Data Set (MDS) assessment, dated 10/25/24, indicated a Brief Interview for Mental Status exam score was not able to be obtained and Resident #78 was assessed by staff to have severely impaired cognition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0699 Review of Resident #78's medical record failed to indicate a trauma assessment had been completed.

Level of Harm - Minimal harm or Review of Resident #78's active plan of care failed to indicate a PTSD care plan with resident specific potential for actual harm triggers and interventions.

Residents Affected - Few During an interview on 1/7/25 at 2:21 P.M., the Director of Clinical Operations #1 said that any resident with PTSD should have a resident specific care plan in plan with specific triggers and interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm 44095 Residents Affected - Few Based on observation, record review and interview the facility failed to ensure that bilateral side rails were implemented in accordance with the care plan, for one Resident (#74) out of a total sample of 24 residents.

Findings include:

Resident #74 was admitted to the facility in January 2023 with diagnoses including traumatic brain injury, history of falling, and muscle weakness.

Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #74 was rarely/ never understood. The MDS further indicated Resident #74 was dependent on staff for activities of daily living.

On 1/6/25 at 7:36 A.M., 1/7/25 at 6:39 A.M., and on 1/9/25 at 6:44 A.M., the surveyor observed Resident #74

in his/her bed. The bilateral side rails were in the middle of the bed. There was 31 inches from the headboard to the top of the side rail, the side rail measured 25 inches, and then there was 27 inches between the bottom of the side rail and the foot of the bed.

Review of Resident #74's plan of care related to activities of daily living, dated as revised 1/25/23, indicated:

-Bed mobility-dependent of two.

Review of Resident #74's form titled, Side Rail Consent Form, undated, indicated that this consent is for the use of side rails on this resident's bed for bed mobility only.

Date of Discussion: left blank.

Last Reviewed by facility: left blank.

Risks/ Benefits: left blank.

Entrapment/ Enabler

( ) By Checking here and by my signature below, I give consent for side rails to be used for bed mobility only. My signature also indicates that I understand the risk and benefits of side rails. Signed by the Resident's representative on 1/18/23. (not checked off as consenting)

Review of Resident #74's plan of care related to side rails, dated 1/25/23, indicated:

-Resident or Resident health representative has consented to the use of assertive device.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0700 -Grab bars to be used as an enabler for bed mobility.

Level of Harm - Minimal harm or Review of Resident #74's physician's order failed to include the type and size of the side rail. potential for actual harm

Review of Resident #74's the NSH Nursing Evaluation - V 18, dated 1/4/25, indicated: Residents Affected - Few Section B. Musculoskeletal.

m. Type of Rail Needed:

-Bilateral

During an interview on 1/9/25 at 7:37 A.M., Certified Nursing Assistant (CNA) #2 said Resident #74 is totally dependent for care. CNA #2 said that Resident #2 has two side rails in the middle of his/her bed to keep him/her in bed.

During an interview on 1/9/25 at 9:28 A.M., the Director of Clinical Operations #2 said Resident #74 should have his/her side rails based on the side rail assessment and the care plan.

On 1/9/25 at 10:58 A.M., the surveyor observed the Maintenance Director measure Resident #74's bilateral side rails. There was 31 inches from the headboard to the top of the side rail, the side rail measured 25 inches, and there was 27 inches between the bottom of the side rail and the foot of the bed.

On 1/9/25 at 11:07 A.M., the surveyor and the Director of Clinical Operations #2 observed Resident #27 in bed. The Director of Clinical Operations #2 said that the side rails on Resident #74's bed are not grab bars.

During an interview on 1/9/25 at 12:33 P.M., the Administrator said the facility did not have a policy for side rails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 44095 minimal harm Based on observations and interviews, the facility failed to post nursing staff data daily, at the start of each Residents Affected - Some shift, as required.

Findings include:

On 1/6/25 at 6:47 A.M., and at 5:00 P.M., and on 1/7/25 at 6:40 A.M., the surveyor observed the daily staffing posted at the front of the facility dated Wednesday December 25, 2024.

On 1/8/25 at 11:47 A.M. and at 4:37 P.M., the surveyor observed the daily staffing posted at the front of the facility dated Tuesday January 7, 2025.

On 1/9/25 at 6:52 A.M., the surveyor observed the daily staffing posted at the front of the facility dated Tuesday January 7, 2025.

During an interview on 1/9/25 at 11:23 A.M., the Scheduling Coordinator said she is responsible for printing

the staff data daily to the reception printer. The Scheduling Coordinator said the Administrator, or the Receptionist will post the staff data.

During an interview on 1/9/25 at 12:32 P.M., the Administrator said that nurse staffing should be posted as required.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 36797 potential for actual harm Based on observations, record review, and interviews, the facility failed to ensure it was free from a Residents Affected - Few medication error rate of greater than 5% when one out of four nurses observed made 10 errors out of 43 opportunities, resulting in a medication error rate of 20.93%. Those errors impacted two Residents (#34 and #77).

Findings include:

Review of the facility policy titled Administering Medications, dated as revised 9/2024, indicated that medications are administered in a safe and timely manner and as prescribed. Further review indicated that medications may be administered one hour before or after the prescribed time, unless otherwise specified.

1. Resident #34 was admitted to the facility in March 2015 with diagnoses including diabetes, Alzheimer's and high blood pressure.

On 1/7/25, at 8:25 A.M. the surveyor observed Nurse #10 administer the following medications to Resident #34:

-Aspirin Enteric Coated 81 mg. (milligrams) one tablet;

-Metformin 500 mg. one tablet; and

-Vitamin D 10 mg one tablet.

Review of Resident #34's physician's orders dated January 2025, indicated the following medications to be administered at 8:00 A.M., and 9:00 A.M.

-Aspirin Enteric Coated 81 mg. (milligrams) one tablet at 8:00 A.M.

-Metformin 500 mg. one tablet at 8:00 A.M.

-Vitamin D 10 mg one tablet at 8:00 A.M.

-Glipizide 5 mg one tablet at 8:00 A.M. (did not give)

-Lokelma oral packet 10 GM (grams) one packet by mouth at 8:00 A.M. (did not give)

-Miralax Powder 17 GM at 8:00 A.M. (did not give)

-Atenolol 25 mg one tablet at 8:00 A.M. (did not give)

-Namanda 5 mg one tablet at 8:00 A.M. (did not give)

-B-12 100 mcg (micrograms) at 9:00 A.M. (did not give)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0759 -Ferrous Sulfate 325 mg one tablet at 9:00 A.M. (did not give)

Level of Harm - Minimal harm or 2. Resident #77 was admitted to the facility in March 2024 with diagnoses including heart disease, adult potential for actual harm failure to thrive and high blood pressure.

Residents Affected - Few On 1/7/25, at 8:30 A.M. the surveyor observed Nurse #10 administer the following medications to Resident #77:

-Atorvastatin 80 mg one tablet;

-Omeprazole 20 mg one tablet;

-Aspirin 81 mg one tablet; and

-Ferrous Sulfate 324 mg one tablet.

Review of Resident #77's physician's orders dated January 2025, indicated the following medications to be administered at 8:00 A.M., and 9:00 A.M.

-Atorvastatin 80 mg one tablet at 8:00 A.M.

-Omeprazole 20 mg one tablet at 8:00 A.M.

-Aspirin 81 mg one tablet at 8:00 A.M.

-Ferrous Sulfate 324 mg one tablet at 8:00 A.M.

-Amlodipine Besylate 10 mg one tablet at 8:00 A.M. (did not give)

-Metoprolol Succinate Extended Release 12.5 mg one tablet at 8:00 A.M. (did not give)

During an interview on 1/7/25 at 2:21 P.M., the Director of Clinical Operations #1 said that all scheduled medications should be given at the time ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 41105 Residents Affected - Few Based on observation and interview the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional standards of practice. Specifically:

1. A medication nurse gave the keys, including narcotic keys to an unassigned staff nurse, providing that nurse access to their medication cart; and

2. Nursing failed to secure the medication cart on 1 of 3 nursing units.

Findings include:

1. On 1/6/25 at 8:26 A.M., a nurse entered the 3rd floor dining room, asked Nurse #1 for the keys to his medication cart. The nurse then walked across the room to Nurse #1's medication cart, unlocked the cart, briefly accessed the cart, then locked it and returned the keys to Nurse #1. While the nurse was in Nurse #1's cart, Nurse #1 had his back to the cart and was assisting a resident.

During an interview with the Director of Clinical Operations #1 on 1/7/25 at 2:22 P.M., she said that it is her expectation that nurses maintain the keys to their own medication cart and not allow other nurses to access

the cart. She said the nurse that has the keys to a cart is responsible for the medication in the cart, including narcotics.

2. On 1/6/25 at 12:10 P.M., the surveyor observed, opened, and accessed an unlocked medication cart in

the 3rd floor unit dining room. There were five residents on the side of the room where the cart was located. Nurse #1 was observed across the room sanitizing the hands of residents in the room and was unaware that

the surveyor was able to access the medication cart.

During an interview on 1/6/25 at 12:11 P.M., Nurse #1 said that the medication cart should always be locked when not attended.

On 1/7/25 at 8:06 A.M., the surveyors observed, opened, and accessed an unlocked medication cart in the 3rd floor unit dining room. There were three residents on the side of the room where the cart was located. Nurse #1 was observed across the room serving a resident breakfast and was unaware that the surveyor was able to access the medication cart.

During an interview on 1/7/25 at 8:07 A.M., Nurse #1 said that the medication cart should always be locked when not attended.

During an interview with the Director of Clinical Operations #1 on 1/7/25 at 2:22 P.M., she said that it is her expectation that medication carts be locked when unattended.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or 44095 potential for actual harm Based on record review and interviews, the facility failed to ensure laboratory services were provided for one Residents Affected - Some Resident (#7) out of a sample of 24 Residents. Specifically, the facility failed to ensure routine labs were obtained according to the physician's orders.

Findings include:

Review of the facility policy titled, Lab and Diagnosis Test Results - Clinical Protocol, dated 2/2020, indicated

the following:

1. The physician will identify, and order diagnosis and lab testing based on the resident's diagnostic and monitoring needs.

2. The staff will process test requisitions and arrange for tests.

Resident #7 was admitted to the facility in July 2024 with diagnoses including dementia, tracheostomy, diabetes, and seizures.

Review of the most recent Minimum Data Set (MDS) assessment, dated 10/4/24, indicated that Resident #7 was comatose.

Review of Resident #7's current physician's order, with a start date of 7/4/24, indicated:

-CBC, CMP, LFT, Magnesium, and phosphorus every Tuesday and Thursday.

(CBC, complete blood count is a blood test that measures amounts and sizes of your red blood cells, hemoglobin, white blood cells and platelets)

(CMP, comprehensive metabolic panel is a blood test that measures 14 different substances like proteins and electrolytes in the blood.)

(LFT, liver function tests are blood tests that measure different substances produced by the liver, including proteins, enzymes, and bilirubin.)

(Magnesium, a blood test that measures the amount of magnesium in a sample in blood. The body needs magnesium to help muscles, nerves, and heart work properly. Magnesium also helps control blood pressure and blood glucose, also called blood sugar)

(Phosphorus, phosphate in blood test measures the amount of phosphate in a sample of the blood. Phosphate contains a mineral named phosphorus. Phosphate is a type of electrolyte. Electrolytes are electrically charged minerals. They help control the amount of fluids and the balance of acids and bases (pH balance) in the body.)

Review of Resident #7's current physician's order, with a start date of 7/16/24, indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0770 -CBC and CMP weekly on Tuesday.

Level of Harm - Minimal harm or Review of Resident #7's current physician's order, with a start date of 9/10/24, indicated: potential for actual harm -Weekly CBC and CMP. Residents Affected - Some

Review of Resident #7 laboratory results in the electronic health record and paper medical record indicated

the following results:

-BMP and CBC obtained on 11/19/24. (BMP, a basic metabolic panel, is a blood test that measures eight different substances in your blood.)

-BMP and CBC obtained on 12/3/24

-CBC and CMP obtained on 1/1/25

During an interview on 1/9/25 at 1:56 P.M., Nurse #2 said when labs are ordered it is the nurses' responsibility to put a lab slip in the book for the labs to be obtained.

During an interview on 1/9/25 at 9:09 A.M., the Director of Clinical Operations #2 said labs should be obtained based on the physician's orders. She was unable to provide the surveyor with any additional labs and said that she was unable to find lab work that consistently corresponded with the active physician's orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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** 36797 potential for actual harm Based on observations, interviews and record reviews, the facility failed to provide dental services for one Residents Affected - Few Resident (#85) out of a total sample of 24 residents.

Findings include:

Review of the policy titled Dental Services, dated as revised 11/2017, indicated:

-Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.

-All dental services provided are recorded in the resident's medical record.

Resident #85 was admitted to the facility in January 2024 with diagnoses including kidney disease, heart disease and alcohol use.

Review of the January 2025 Physician's orders for Resident #85 indicated an order dated 1/19/24: may have dental consults.

Review of the progress note, dated 12/6/24, indicated that right before dinner the Resident stated that (he/she) was having mouth discomfort. Upon examination, this writer noted some redness/inflammation on

the gums around the base of one of the Resident's front teeth. PA (physician's assistant) notified and ordered 500 mg of Amoxicillin three times a day for seven days. Resident will also be added to (dental services) to be seen by the dentist when they arrive to the facility on [DATE REDACTED]th.

Review of the medical record failed to indicate that Resident #85 was seen by the dentist on 12/10/24 or any time since then.

During an interview on 1/7/25 at 2:21 P.M., the Director of Clinical Operations #1 said that if a resident has swelling of the gums and pain in the mouth the expectation that a dental consult would be obtained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44095

Residents Affected - Some Based on observations and interviews, the facility failed to adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in the facility's main kitchen. Specifically, the facility failed to implement safe food practices in the main kitchen relative to discarding food that was spoiled and labeling/dating guidelines.

Findings include:

Review of the facility policy titled, Food and Supply Storage, dated as revised ,d+[DATE REDACTED], indicated food, non-food items, and supplies used in food preparation and service shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as outlined in the Federal Drug Administration Food Code, state regulations, and city/county health codes.

Guidelines

2. Labeling and rotating food supply

a. Food products that are opened and not completely used; transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and used by dates.

b. Rotate food products (dry, refrigerated, or frozen) to ensure the oldest inventory is used first, commonly known as FIFO-First In First Out.

1) Two methods for implementing FIFO:

a) A product use by date or delivery date is marked on the product. Employees stock shelves with earliest used by dates or delivery dates in front of products with later dates. Then, products in the front are used first.

b) Before shelving new stock, mark all containers currently on the shelf with a FIFO sticker or a color-coded sticker. Employees to pull stickered products forward and stock newer products behind. Then, products with FIFO stickers are used first. This method is acceptable for those operations that use stock quickly.

4. Discard food that exceeds their use-by date or expiration date, is damaged, is spoiled, has the time and temperature danger zone requirements, or incorrectly stored such that it is unsafe, or its safety is uncertain.

On [DATE REDACTED] at 7:01 A.M., during an initial walk through of the facility's kitchen the surveyor observed the following:

In the reach in refrigerator:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 -Five brown squares of cake or brownie type food, unlabeled and undated.

Level of Harm - Minimal harm or -Seven pieces of pumpkin pie, unlabeled and undated. potential for actual harm

In the walk-in refrigerator: Residents Affected - Some -1 package of sliced cheese. ,d+[DATE REDACTED] of the cheese was dry and open to air, and undated.

-1 package of mozzarella cheese, opened and undated.

-1 container of orange slices, dated as opened [DATE REDACTED] and use by [DATE REDACTED].

-1 container of chicken soup, dated as opened [DATE REDACTED] and use by [DATE REDACTED].

-1 box of tomatoes, 9 tomatoes had black spots and gray fuzz on them.

-1 box of mixed greens, wilted and opened to the air.

-1 plastic container of red peppers, green peppers, carrots, cucumbers, and a lime. There were three red peppers that had black spots and gray fuzz, a cucumber was mushy and soft, and a green pepper that was mushy and soft. There was a lime that was brown.

In a reach in refrigerator in the dry storage room:

-1 loaf of raisin bread dated [DATE REDACTED].

-1 loaf of raisin bread dated [DATE REDACTED].

-2 loaves of wheat bread, dated [DATE REDACTED], firm to touch.

-6 packages of dinner rolls, without dates.

In the dry storage room:

-1 container of breadcrumbs, opened and undated.

-1 container of flour, opened and undated.

-7 different containers of dry cereal opened and undated.

During the follow-up kitchen tour on [DATE REDACTED] the following observations were made:

In the walk-in refrigerator:

-1 plastic container of red peppers, green peppers, carrots, cucumbers, and three limes. There were three red peppers that had black spots and gray fuzz and there were three brown limes.

In the dry storage room:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 -1 container of breadcrumbs, opened and undated.

Level of Harm - Minimal harm or -1 container of flour, opened and undated. potential for actual harm

In a reach in refrigerator in the dry storage room: Residents Affected - Some -1 loaf of raisin bread dated [DATE REDACTED].

-3 loaves of raisin bread dated [DATE REDACTED].

-6 packages of dinner rolls, without dates.

During an interview of [DATE REDACTED] at 10:11 A.M., the Food Service Director (FSD) said he knows when the dinner rolls are good, based on when they come in from the delivery even though the dinner rolls are undated.

During an interview on [DATE REDACTED] at 10:13 A.M., the Corporate Food Service Director said expired and outdated foods should be discarded of, and foods without dates should be dated once opened.

During an interview on [DATE REDACTED] at 12:32 P.M., the Administrator said the Food Service Director is responsible for ensuring expired foods are discarded and food items are labeled when opened.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 41105

Residents Affected - Few Based on observation, record review and interview the facility failed to ensure accuracy of the medical record for two Residents (#90 and #88) out of a total sample of 24 residents. Specifically:

1. For Resident #90 nursing documented in the Treatment Administration Record (TAR) that a bed was in

the lowest position and that fall mats were in place when they were not; and

2. for Resident #88 the facility failed to accurately document in the Medication Administration Record (MAR) when medications were administered.

Findings include:

1. Resident #90 was admitted to the facility in May 2024 and has diagnoses that include dementia without behavioral disturbance and muscle weakness.

Review of the most recent Minimum Data Set (MDS) assessment, dated 9/30/24, indicated that Resident #90 was assessed by staff to have severe cognitive impairment. The MDS further indicated Resident #90 required substantial to maximal assist with bed mobility.

Review of the most recent Nursing Evaluation, dated 12/23/24, indicated Resident #90 had sustained 1-2 falls within the last six months.

Review of the current physician's orders indicated the following order:

-Make sure the bed is in the lowest position and floor mats are in place when resident is in bed, start date 8/1/24.

Review of the January 2025 TAR indicated the following:

-Nursing documented that Resident #90's bed was in the lowest positions with floor mats in place daily on all three shifts.

On 1/6/25 at 8:51 A.M., Resident #90 was observed asleep in bed. The bed was at a regular height and there was a fall mat on the left side of the bed, but none on the right side. A second fall mat was not observed in the room.

On 1/7/25 at 6:54 A.M., Resident #90 was observed asleep in bed. The bed was in the lowest position, however there was no fall mat on the right side of the bed, only on the left. A second fall mat was not observed in the room.

On 1/7/25 at 7:54 A.M., Resident #90 was observed asleep in bed. The bed was in the lowest position, however there was no fall mat on the right side of the bed, and the fall mat on the left side of the bed was now 2-3 feet away from the bed, exposing Resident #90 directly to the floor should he/she fall. A second fall mat was not observed in the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0842 On 1/7/25 at 9:56 A.M., Resident #90 was observed asleep in bed. The bed was in the lowest position, however there was no fall mat on the right side of the bed, and the fall mat on the left side of the bed Level of Harm - Minimal harm or remained 2-3 feet away from the bed, exposing Resident #90 directly to the floor should he/she fall. A potential for actual harm second fall mat was not observed in the room.

Residents Affected - Few On 1/9/25 at 7:25 A.M., Resident #90 was observed asleep in bed. The bed was at a regular height and there was a fall mat on the left side of the bed, but none on the right side. A second fall mat was not observed in the room.

On 1/9/25 at 8:13 A.M., Resident #90 was observed asleep in bed. The bed was at a regular height and there was a fall mat on the left side of the bed, but none on the right side. A second fall mat was not observed in the room.

During an interview on 1/9/25 at 11:31 A.M., with Resident #90's Certified Nursing Assistant (CNA) #4 she said that she was not aware that Resident #90's bed was supposed to be in the lowest position with fall mats

in place. CNA #90 said that she usually gets report at the start of a shift on a resident's care needs but because she was moved to the floor at 10:30 A.M., that morning she had not.

During an interview on 1/9/25 at 11:39 A.M., with Resident #90's Nurse #6 she said that it was the expectation that the documentation in the TAR be accurate, therefore if the TAR indicates that the bed was

in the lowest position with fall mats in place, that is what she would expect had occurred.

During an interview with the Director of Clinical Operations #2 on 1/9/25 at 12:37 P.M., she said that it is her expectation that the TAR be accurate and accurately reflect what has been done.

49880

2. Resident #88 was admitted to the facility in November 2024 with diagnoses that include end stage renal disease and dependence on renal dialysis.

Review of Resident #88's most recent Minimum Data Set (MDS) Assessment, dated 11/26/24, indicated a Brief Interview for Mental Status exam score of 15 out of 15, indicating intact cognition.

Review of Resident #88's current physician's orders indicated the following medications ordered with administration times of 6:00 A.M.:

-Aspirin 81 milligrams (mg) EC (enteric Coated) once daily, dated 11/22/24.

-B Complex- Vitamin C capsule once daily, dated 11/21/24.

-Clopidogrel Bisulfate Tablet 75 mg once daily for blood clot prevention, dated 11/21/24.

-Isosorbide Mononitrate ER (extended release) tablet 60 mg, once daily for blood pressure, dated 11/30/24.

-Losartan Potassium 100 mg once daily for blood pressure, dated 11/21/24.

-Nifedipine ER 60 mg once daily for hypertension, dated 11/21/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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

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

F 0842 -Carvedilol 25 mg, give 1.5 tablets twice daily for hypertension, dated 12/4/24.

Level of Harm - Minimal harm or Review of Resident #88's December 2024 Medication Administration Record (MAR) indicated the following: potential for actual harm -6:00 A.M. medications are not signed off as administered on 12/8/24, 12/10/24, 12/16/24, 12/20/24, Residents Affected - Few 12/23/24, 12/28/24, 12/30/35. The MAR and clinical progress notes failed to indicate a reason why the medications were not signed off.

Review of the January 2025 MAR indicated the following:

-6:00 A.M. medications are not signed off as administered on 1/1/25 and 1/5/25. The MAR and clinical progress notes failed to indicate a reason why the medications were not signed off.

During an interview on 1/10/25 at 10:06 A.M., Nurse #8 said that she worked overnight on some of these occasions and the medications were administered. She said she forgot to sign them off because sometimes

the Resident likes to wait until he/she has something to eat to take medications with. She said the medical

record is inaccurate and should have been signed off as administered.

During an interview on 1/10/25 at 10:16 A.M., the Director of Clinical Operations #2 said that she would expect the medical record to be accurate and reflect the medications that are administered to a resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 36797 potential for actual harm Based on observation, record review and interview the facility failed to establish and maintain an infection Residents Affected - Some prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two Resident (#16, #88) out of a total sample of 24 residents and on 1 of 3 resident units. Specifically:

1. For Resident #16, the facility failed to implement Enhanced Barrier Precautions (EBP) due to a peripherally inserted central catheter (PICC) line.

2. For Resident #88, the facility failed to implement EBP due to an external dialysis catheter

3. The facility failed to ensure that during meal pass, soiled dishware was not put back in the carts with meals awaiting delivery to residents.

Findings Include:

Review of facility policy, titled Infection Control Guidelines for Nursing Procedures, dated as revised 7/2024, indicated the following:

-Policy: To provide guidelines for general infection control while caring for residents.

-Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDROs)

-EBP is indicated for nursing home residents with any of the following: Indwelling medical devices, including but not limited to i.e., IV (intravenous) feeding tubes, trach, drains/ pleurex, urinary catheter.

-PPE (used with EBP) Use of gown and gloves during high- contact resident care activities that may provide opportunities for transmission of MDROs via staff hands and clothing.

1. On 1/7/25 at 8:39 A.M., the surveyor observed a sign on the Resident #16's door indicating that enhanced barrier precautions were in effect for Resident #16.

On 1/7/25 at 8:39 A.M., the surveyor observed Nurse #9, administer intravenous (IV) medication to Resident #16. The surveyor observed that Nurse #9 did not wear gown during the high contact procedure. The surveyor observed Nurse #9 leaning over Resident #16, with the front of her clothing touching Resident #16's bed linens.

During an interview on 1/7/25 at 8:42 A.M., Nurse #9 said she did not know she was supposed to wear a gown.

49880

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 2. Resident #88 was admitted to the facility in November 2024 with diagnoses that include end stage renal disease and dependence on renal dialysis. Level of Harm - Minimal harm or potential for actual harm Review of Resident #88's most recent Minimum Data Set (MDS) assessment, dated 11/26/24, indicated a Brief Interview for Mental Status exam score of 15 out of 15, indicating intact cognition. The MDS further Residents Affected - Some indicated that Resident #88 received Hemodialysis.

On 1/9/25 at 7:29 A.M., Resident #88 was observed sleeping in bed, no EBP were in place. There was no sign outside the Resident room indicating the need for EBP. Resident #88 was observed to have an external right chest catheter for dialysis access.

On 1/9/25 at 11:18 A.M., Resident #88 was observed in his/her room. There was no sign outside of the Resident's room indicating the need for EBP. Resident #88 was observed to have an external right chest catheter for dialysis access.

Review of current physician's orders indicated the following order, dated 12/3/24, monitor dialysis access site to right jugular catheter, if bleeding occurs- apply clamp and call 911.

Review of Resident #88's care plan indicated an active care plan for an IV (intravenous) access line: potential for infection and or trauma related to catheter direct access to blood.

During an interview on 1/9/25 at 11:16 A.M., Nurse #7 said that Resident #88 is not on Enhanced Barrier Precautions, but he/she should be due to the external dialysis catheter.

During an interview on 1/9/25 at 11:19 A.M., Nurse #4 said that Resident #88 was admitted with the external dialysis catheter in place. She said that Resident #88 should be on Enhanced Barrier Precautions, but he/she is not.

During an interview on 1/9/25 at 12:37 A.M., the Director of Clinical Operations said that a Resident with a right chest catheter should be placed on Enhanced Barrier Precautions because the external catheter placed them at increased risk for infection.

3. Review of facility policy titled Resident Meal Service and Dining, dated as revised 7/24, indicated the following:

-6. Soiled dishware is not put on carts that have meals awaiting delivery to residents.

During an observation on the third-floor unit on 1/9/25 at 8:56 A.M., third floor unit staff were observed returning soiled resident meal trays into the cart with trays awaiting delivery to residents. A nurse was then observed removing trays from the truck that had not been passed yet and bringing it into a resident and assisting the resident with the meal.

During an interview on 1/9/25 at 12:34 P.M., Director of Clinical Operations #2 that staff should not be placing soiled trays back into the cart with clean ready to pass trays, and this is an infection control concern.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Level of Harm - Minimal harm or potential for actual harm 44095

Residents Affected - Some Based on observation, record review and interview, the facility failed identify and minimize areas of possible entrapment in resident beds. Specifically for Resident #74, out of a total of 24 sampled residents, the facility failed to conduct routine inspections on his/her bed frame and mattress to identify possible areas of entrapment. The facility failed also failed to conduct routine inspections of all bed frames and mattresses to identify possible areas of entrapment for 94 resident beds.

Findings include:

Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/2006, indicated: The term entrapment describes an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Resident entrapments may result in deaths and serious injuries. There are 7 zones of bed entrapment: Zone 1 (within the rail), Zone 2 (under the rail), Zone 3 (between rail and mattress), Zone 4 (Under the rail, at the ends of the rail), Zone 5 (between split bed rails), Zone 6 (between the end of the rail and the side edge of the head or foot board) and Zone 7 (Between the head or foot board and the mattress end).

Review of guidance from the FDA titled Recommendations for Health Care Providers about Bed Rails, dated 07/09/2018, included:

-Inspect and regularly check the mattress and bed rails to make sure they are still installed correctly and for areas of possible entrapment and falls. Regardless of mattress width, length, and/or depth, the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body.

-Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards.

Resident #74 was admitted to the facility in January 2023 with diagnoses including traumatic brain injury, history of falling, and muscle weakness.

Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #74 was rarely/ never understood. The MDS indicated Resident #74 was dependent on staff for activities of daily living.

On 1/6/25 at 7:36 A.M., 1/7/25 at 6:39 A.M., 1/9/25 at 6:44 A.M., the surveyor observed Resident #74 in his/her bed, the bilateral side rails were in the middle of the bed. There were 31 inches from the headboard to the top of the side rail, the side rail measured 25 inches in length, and there was 27 inches between the bottom of the side rail and the foot of the bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 61 225324 Department of Health & Human Services Printed: 09/11/2025 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 225324 B. Wing 01/10/2025

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

West Newton Healthcare 25 Armory Street West Newton, MA 02465

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 0909 On 1/9/25 at 10:45 A.M., the surveyor requested from the Maintenance Director any evidence to support the facility conducted regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular Level of Harm - Minimal harm or maintenance program to identify areas of possible entrapment for Resident #74's bed. The Maintenance potential for actual harm Director provided the surveyor with 20 entrapment assessments which did not include the Resident who was assessed in the bed that had been completed within the last year, the assessments did not address zone Residents Affected - Some seven and there was no assessment for Resident #74's bed.

On 1/9/25 at 10:58 A.M., the surveyor observed the Maintenance Director measure Resident #74's side rails. There was 31 inches from the headboard to the top of the side rail, the side rail measured 25 inches, and there was 27 inches between the bottom of the side rail and the foot of the bed. The Maintenance Director said that this mattress and bedrails would automatically pass the entrapment assessment because of the large gaps between the top of the bed and the side rails and the bottom of the bed and side rail. He said nobody's head could get stuck in a gap that big. The Maintenance Director said he wouldn't even conduct an assessment on this bed because of the large gaps.

On 1/9/25 at 11:07 A.M., the surveyor and the Director of Clinical Operations #2 observed Resident #74 in bed. The DCO #2 said that entrapment assessments need to be completed annually and when there is a change in the device on all residents.

During an interview on 1/9/25 at 12:33 P.M., the Administrator said there were no policy or protocols in place to periodically ensure beds are assessed for entrapment. The Administrator said there was a current census of 94 and the Maintenance Director would need to evaluate all beds for entrapment.

During a follow up interview on 1/9/25 at 1:03 P.M., the Maintenance Director said he was not aware they were supposed to measure all the beds including the headboard (zone 7), footboard (zone 7), and even beds without side rails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 61 225324