Woburn Nursing Center, Inc

F-F760.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 36 225394 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 225394 B. Wing 01/09/2025

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

Woburn Rehabilitation and Nursing Center 18 Frances Street, #3095 Woburn, MA 01801

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or 48990 potential for actual harm Based on observation, interviews, and record review, the facility failed to ensure one Resident (#72) was free Residents Affected - Few from significant medication errors, out of a total sample of 29 residents. Specifically, Nurse #2 attempted to administer medications to the incorrect Resident (#72), including medications that the Resident was allergic to and medications that could jeopardize his or her health and safety.

Findings include:

According to the U.S. Food and Drug Administration prescribing information for amoxicillin/clavulanate potassium (a penicillin-based antibiotic), dated December 2006, indicated:

- Amoxicillin/clavulanate potassium should be used by prescription only.

- Amoxicillin/clavulanate potassium is contraindicated in patients with a history of allergic

reactions to any penicillin.

- Serious and occasionally fatal hypersensitivity (anaphylactic) reactions have been reported in patients on penicillin therapy. These reactions are more likely to occur in individuals with a history of penicillin-hypersensitivity. Before initiating therapy with amoxicillin/clavulanate potassium, careful inquiry should be made concerning previous hypersensitivity reactions to penicillins. If an allergic reaction occurs, amoxicillin/clavulanate potassium should be discontinued and the appropriate therapy instituted. Serious anaphylactic reactions require immediate emergency treatment with epinephrine, oxygen, intravenous steroids, and airway management, including intubation should also be administered as indicated.

According to the U.S. Food and Drug Administration prescribing information for flecainide acetate (an antiarrhythmic medication used to prevent or treat irregular heartbeats), dated December 2024, indicated:

- Flecainide acetate should be used by prescription only.

- Flecainide acetate, like other antiarrhythmic agents, can cause new or worsened supraventricular or ventricular arrhythmias. Ventricular proarrhythmic effects range from an increase in frequency of PVCs to the development of more severe ventricular tachycardia, e.g., tachycardia that is more sustained or more resistant to conversion to sinus rhythm, with potentially fatal consequences.

According to the U.S. Food and Drug Administration prescribing information for escitalopram oxalate (an antidepressant medication), dated August 2023, indicated:

- Escitalopram oxalate should be used by prescription only.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 36 225394 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 225394 B. Wing 01/09/2025

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

Woburn Rehabilitation and Nursing Center 18 Frances Street, #3095 Woburn, MA 01801

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 0760 - Increased risk of suicidal thoughts and behavior in pediatric and young adult patients taking antidepressants. Closely monitor all antidepressant-treated patients for clinical worsening and emergence of Level of Harm - Minimal harm or suicidal thoughts and behaviors potential for actual harm

Review of the facility policy titled 'Medication Administration', dated as reviewed September 2024, indicated: Residents Affected - Few - Identify resident by photo in the MAR (medication administration record).

- Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Resident #72 was admitted to the facility in December 2024 with diagnoses including chronic heart failure, acute kidney injury, and allergies to penicillin and aspirin.

Review of the most recent Minimum Data Set (MDS) assessment, dated 12/19/24, indicated Resident #72 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.

On 1/7/25 at 8:14 A.M., the surveyor observed Nurse #2 tell Resident #72's roommate that he would bring his/her morning medication in right away.

On 1/7/25 at 8:19 A.M., the surveyor observed Nurse #2 prepare medications including:

- Amoxicillin-Potassium Clavulanate (a penicillin-based antibiotic) 875-125 mg, 1 tablet.

- Aspirin 81 mg, 1 tablet

- Flecainide Acetate (used to prevent or treat irregular heartbeats) 100 mg, 1 tablet.

- Escitalopram oxalate (an antidepressant) 20 mg, 1 tablet.

On 1/7/25 at 8:37 A.M., Nurse #2 placed the prepared medications on Resident #72's bedside table and told Resident #72 it was his/her medications. Nurse #2 did not request the Resident to verify their name, date of birth, or any identifying information. Nurse #2 did not check the Resident's identification bracelet. Resident #72 asked what these medications were and Nurse #2 repeated that it was his/her medications and to take them. The surveyor intervened and asked if these medications were supposed to be for the roommate (Resident #37). Nurse #2 said they were not, and they were for Resident #72. Nurse #2 moved the medications closer to the Resident and again said to take the medications. Resident #72 presented as confused and stared from the medications to the nurse multiple times. After a short time, Nurse #2 picked up

the medication and left Resident #72's bedside. At this point, Nurse #2 said he was glad the surveyor intervened because he thought he had prepared Resident #72's medication but should have checked that it was the correct Resident's medication before attempting to administer them because there were some medications that could have jeopardized the Resident's health and safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 36 225394 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 225394 B. Wing 01/09/2025

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

Woburn Rehabilitation and Nursing Center 18 Frances Street, #3095 Woburn, MA 01801

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 0760 During an interview on 1/7/25 at 11:14 A.M., the Director of Nursing (DON) said Nurse #2 should have verified Resident #72 was the same Resident that the medications were ordered for prior to attempting to Level of Harm - Minimal harm or administer the medications. The DON said the resident's identity should be verified in two ways before every potential for actual harm medication administration, including ways such as checking the photograph in the medical record, checking identification bracelet, or asking the resident to identify themselves. The DON said Resident #72 is on a busy Residents Affected - Few rehabilitation floor that is a revolving door making it especially important to verify identification prior to administering medications. The DON said residents should not be administered medications that they are allergic to but declined to answer any further questions about the significance of the other medications attempted to be administered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 36 225394 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 225394 B. Wing 01/09/2025

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

Woburn Rehabilitation and Nursing Center 18 Frances Street, #3095 Woburn, MA 01801

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 48990 Residents Affected - Some Based on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically,

1.) The facility failed to ensure medications were stored in secured areas and not left unsecured in residents' rooms.

2.) The facility failed to properly secure treatment carts on two of four units.

3.) The facility failed to ensure medications were dated once opened, according to manufacturer's guidelines,

in two out of four medication carts observed.

Review of the facility policy titled 'Medication Storage', dated as reviewed September 2024, indicated:

- It is the policy of this facility to ensure all medications housed on our premises will be stored according to manufacturer's recommendations.

- All drugs and biologicals will be stored in locked compartments.

- Only authorized personnel will have access to the keys to locked compartments.

Review of the facility policy 'Resident Self-Administration of Medication, dated as reviewed September 2024, indicated:

- Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: the manner of storage prevents access by other residents.

1.) During an observation of the B Unit on 1/6/25 at 8:07 A.M., the surveyor observed the following medications clearly visible and unsecured in resident rooms:

- One bottle of glycerin suppositories (a laxative administered rectally).

- One tube of diclofenac gel (a topical pain reliever) on a dresser.

- One bottle of metamucil (a fiber supplement with laxative properties) on a windowsill.

- Two unopened lidocaine patch (a topical pain reliever) packets on a nightstand.

- One bottle of artificial tears eye drops on a bedside table.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 36 225394 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 225394 B. Wing 01/09/2025

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

Woburn Rehabilitation and Nursing Center 18 Frances Street, #3095 Woburn, MA 01801

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 During observations of the B Unit on 1/6/25 at 1:23 P.M., the surveyor observed the following medications clearly visible and unsecured in resident rooms: Level of Harm - Minimal harm or potential for actual harm - One bottle of glycerin suppositories.

Residents Affected - Some - One tube of diclofenac gel on a dresser.

- One bottle of metamucil on a windowsill.

- Two unopened lidocaine patch packets on a nightstand.

- One bottle of artificial tears eye drops on a bedside table.

During a follow up tour of the B Unit on 1/7/25 at 8:09 A.M.,

- One bottle of glycerin suppositories.

- Two unopened lidocaine patch packets on a nightstand.

- One bottle of artificial tears eye drops on a bedside table.

During an initial tour of the D Unit on 1/6/25 at 9:24 A.M., the surveyor observed the following medication clearly visible and unsecured in a resident room.

- One container of nicotine mini mouth/throat lozenge 4 mg (milligram) container on the bedside table with about 7-8 lozenges were on the table surface next to the container.

During an interview on 1/9/25 at 8:18 A.M., Unit Manager #2 said that medications cannot be stored at bedside unless they have a self-administration of medication assessment completed to assess the resident's ability to ensure that medications are stored safely and securely. Unit Manager #2 said there are no residents on the B Unit who have had this assessment completed and there should be no medications stored at bedside. The surveyor reviewed to medications observed at bedside and Unit Manager #2 said glycerin suppositories, diclofenac gel, metamucil, lidocaine patches, and artificial tears eye drops should not be have been stored unsecured in resident's rooms.

During an interview on 1/9/25 at 8:28 A.M., Nurse #4 said nicotine lozenges are a medication. Nurse #4 said nicotine lozenges should not be stored in any resident rooms without having a self-administration of medication assessment completed to assess the resident's ability to ensure that medications are stored safely and securely. Nurse #4 said this had not been completed and the nicotine lozenges should not have been stored in the resident's room.

During an interview on 1/9/25 at 8:40 A.M., the Director of Nursing (DON) said that medications cannot be stored at bedside unless the resident had a self-administration of medication assessment completed to assess the resident's ability to ensure that medications are stored safely and securely. The DON said she was not aware of any residents in the building who currently are able to have any medications stored at bedside. The DON said there should be no medications stored unsecured at bedside in the facility, including glycerin suppositories, diclofenac gel, metamucil, lidocaine patches, artificial tears eye drops, and nicotine lozenges.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 36 225394 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 225394 B. Wing 01/09/2025

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

Woburn Rehabilitation and Nursing Center 18 Frances Street, #3095 Woburn, MA 01801

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 2.) On 1/7/25 at 1:14 P.M., the surveyor observed C Unit treatment cart unlocked in the hallway. The nurse was not within sight line of the medication cart. The surveyor observed multiple prescription topical Level of Harm - Minimal harm or medications within this treatment cart. potential for actual harm

During an interview on 1/7/25 at 1:16 P.M., Nurse #1 returned to the C Unit treatment cart and said the Residents Affected - Some treatment cart should have been locked when not within her view.

On 1/7/25 at 11:40 A.M., the surveyor observed the D Unit treatment cart unlocked and unattended in the hallway.

On 1/7/25 at 1:22 P.M., the surveyor observed the D Unit treatment cart unlocked and unattended in the hallway. The nurse was not within sight line of the medication cart. The surveyor observed multiple prescription topical medications within this treatment cart.

During an interview on 1/7/25 at 1:32 P.M., Nurse #3 said she should have locked her D Unit treatment cart because it was not within her view.

During an interview on 1/9/25 at 8:40 A.M., the Director of Nursing (DON) said treatment carts should be looked when unattended and not within the nurse's view.

3a.) On 1/7/25 at 1:32 P.M., the surveyor and Nurse #3 observed the following in the Unit D right medication cart:

- One bottle of proheal (liquid protein), open and undated. The proheal bottle label indicated to discard 60 days after opening date.

- One vial of insulin lantus 100 units/ml (u/ml), open and undated.

- One insulin lispro kwik pen (a disposable pen containing insulin) 100 u/ml, open with two different dates on it. The first date was 11/29/24 (which is 40 days after the opening date), and the second date was 12/29/24.

During an interview on 1/7/25 at 1:34 P.M., Nurse #3 said the proheal was not dated, but should have been since it should be discarded 60 days after opening. Nurse #3 said insulin should be dated when opened because it must be discarded 28 days after opening. Nurse #3 said the insulin pen should only be dated upon opening, and it should have been discarded since the opening date was unclear. Nurse #3 said all

these open and undated medications were currently being used by residents in the facility.

During an interview on 1/9/25 at 11:23 P.M., the Director of Nursing (DON) said insulin and proheal should be dated when opened because it has a shortened expiry date once opened. The DON said the insulin pen with two dates should have been discarded and not used because the open date was unclear.

3b.) On 1/7/25 at 1:48 P.M., the surveyor and Nurse #2 observed the following in the B Unit left medication cart: One bottle of timolol maleate eye drops, open and undated.

During an interview on 1/7/25 at 1:50 P.M., Nurse #2 said the timolol maleate eye drops were not dated but should have been because it has a shortened expiry date once opened.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 36 225394 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 225394 B. Wing 01/09/2025

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

Woburn Rehabilitation and Nursing Center 18 Frances Street, #3095 Woburn, MA 01801

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 During an interview on 1/9/25 at 11:23 P.M., the DON said timolol maleate eye drops should be dated when opened because it has a shortened expiry date once opened. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 36 225394 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 225394 B. Wing 01/09/2025

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

Woburn Rehabilitation and Nursing Center 18 Frances Street, #3095 Woburn, MA 01801

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

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

F 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41456 potential for actual harm Based on observations, record review and interviews, the facility failed to provide dental services for one Residents Affected - Few Resident (#8) out of a total sample of 29 residents.

Findings include:

Review of the facility policy titled, Dental Services, indicated the following:

-It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the state plan) and emergency dental care.

-Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures.

-The dental needs of each resident are identified through the physical assessment and MDS assessment processes, and are addressed in each resident's plan of care.

-The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location.

Resident #8 was admitted to the facility in January 2023 with diagnoses including pleural effusion.

Review of Resident #8's most recent Minimum Data Set (MDS), dated [DATE REDACTED], indicated he/she had a Brief

Interview for Mental Status (BIMS) score of 13 out of a possible 15 which indicated the Resident was cognitively intact. The MDS also indicated Resident #8 required supervision for oral care tasks.

During an interview on 1/6/25 at 8:08 A.M., Resident #8 said he/she had recently broken his/her left upper tooth and had not yet seen a dentist. The Resident said he/she believed that staff were aware. Resident #8 said he/she had not seen a dentist in a very long time. The Resident's teeth were observed to be discolored.

Review of Resident #8's medical record indicated the following:

-A consent to be treated by the dentist on 4/14/23.

-A physician order, initiated on 4/14/23, May be seen and treated by (dental services provider) as needed.

-Resident #8 was last seen by the dentist on 5/16/23 with a request for an annual exam for May 2024. The medical record failed to indicate this annual exam was completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 36 225394 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 225394 B. Wing 01/09/2025

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

Woburn Rehabilitation and Nursing Center 18 Frances Street, #3095 Woburn, MA 01801

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

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

F 0791 Review of an oral assessment dated [DATE REDACTED] indicated Resident #8 had broken of carious teeth. Review of

the previous oral assessment dated [DATE REDACTED] failed to indicate any broken teeth were observed. Level of Harm - Minimal harm or potential for actual harm Review of Resident #8's care plans, indicated an oral health care plan developed on 12/20/24 which indicated the following interventions: Residents Affected - Few -Have this resident seen by a dentist routinely and as needed.

During an interview on 1/7/25 at 10:55 A.M., Nurse #6 said all residents in the facility are offered dental services and are scheduled for routine dental appointments if requested. Nurse #XX said the dentist typically sees residents every six months but if there is an emergent situation, such as a broken or painful tooth, the resident can be seen immediately. Nurse #6 said she was unaware Resident #8 had a broken tooth and did not know the last time the Resident was seen by the dentist.

During an interview on 1/9/25 at 10:19 A.M., the Unit Coordinator said she is responsible for scheduling dental appointments for the residents in the facility. The Unit Coordinator showed the surveyor the list of residents recently seen by the dentist and Resident #8 was not on this list. The Unit Coordinator said she was unaware Resident #8 had a broken tooth or was signed up to be seen by the dentist.

During an interview on 1/9/25 at 10:14 A.M., the MDS Nurse said she had completed an oral assessment on Resident #8 in December 2024 and had observed the Resident to have a broken tooth and documented it on

the assessment. The MDS Nurse said this prompted her to create an oral risk care plan for the Resident.

Review of the medical record failed to indicate the nurses or medical providers were notified of the broken tooth found on the oral assessment.

During an interview on 1/9/25 at 10:49 A.M., the Director of Nursing said she was unsure of how often residents should be seen by the dentist. The Director of Nursing said she was unaware Resident #8 had a broken tooth and was unaware the Resident had not seen by the dentist since May of 2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 225394 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 225394 B. Wing 01/09/2025

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

Woburn Rehabilitation and Nursing Center 18 Frances Street, #3095 Woburn, MA 01801

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

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

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 41019 potential for actual harm Based on observation and interview, the facility failed to provide meals at an appetizing, palatable, and safe Residents Affected - Some temperature.

Findings include:

During the Resident Group Interview on 1/7/24 at 1:30 P.M., all participating Residents reported that the food at the facility is consistently cold and does not taste good.

During a test tray on 1/7/25 at 12:17 P.M., the following was observed:

- The turkey in gravy was 101 degrees Fahrenheit and tasted lukewarm and bland.

During a test tray on 1/9/25 at 8:15 A.M., the following was observed:

- Milk was 52 degrees Fahrenheit.

- Eggs were 118 degrees Fahrenheit and lukewarm.

During a test tray on 1/9/25 at 8:16 A.M., the following was observed:

- Eggs were 89 degrees Fahreneheit and cold.

During a test tray on 1/9/25 at 8:45 A.M., the following was observed:

- Eggs were 95 degrees Fahrenheit and lukewarm.

- Oatmeal was 115 degrees Fahrenheit and lukewarm.

During an interview on 1/9/25 at 9:20 A.M., the Administrator said she is aware of the issues in the food service department and is planning on doing point of service steam tables to resolve the issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 225394 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 225394 B. Wing 01/09/2025

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

Woburn Rehabilitation and Nursing Center 18 Frances Street, #3095 Woburn, MA 01801

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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41019

Residents Affected - Few Based on observation and interview, the facility failed to provide the appropriate diet texture for one Resident (#91) out of a total sample of 29 residents.

Findings include:

Resident #91 was admitted in April 2024 with diagnoses including adult failure to thrive and dementia.

Review of the Minimum Data Set (MDS), dated [DATE REDACTED], indicated Resident #91 scored a 2 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of the MDS and certified nursing aide documentation, indicates Resident #91 varies from independence to dependence with eating.

Review of the physician's orders for Resident #91 indicated Resident #91 was to receive a pureed diet texture with nectar thickened liquids.

During an observation on 1/9/25 at 8:45 A.M., Resident #91 had a tray at his/her bedside table. The Resident had scrambled eggs on his/her tray that were not pureed.

During an interview on 1/9/25 at 8:46 A.M., Nurse #7 said that he checks the trays, but Resident #91 was served eggs that were not pureed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 36 225394 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 225394 B. Wing 01/09/2025

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

Woburn Rehabilitation and Nursing Center 18 Frances Street, #3095 Woburn, MA 01801

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 41019

Residents Affected - Some Based on observation and interview, the facility failed to follow and maintain foodservice sanitation practices. Specifically, the facility failed to ensure there were thermometers in two refrigerators and failed to accurately

record temperatures of the service line, failed to label and date dry products in the kitchen, and failed to ensure there is safe and properly working equipment in the kitchen.

Findings include:

During an observation on 1/7/25 at 8:08 A.M., the kitchenette on the C and D unit contained opened meat and cheese package and a package of pepperoni that was not labeled and dated.

During an observation on 1/7/25 at 12:02 P.M., the temperature log for 1/7/25 indicated that the temperatures for the dinner meal were already recorded.

During an observation on 1/7/25 at 12:15 P.M., walk in refrigerator and the milk chest refrigerator both were missing thermometers.

During an observation on 1/7/25 at 12:17 P.M., a container of bread crumbs, container of flour, and container of white rice were all not labeled or dated.

During an observation and interview on 1/7/25 at 12:17 P.M., a lighter was sitting next to the gas stovetop burner. The cook said that sometimes he needs to use the lighter to light the middle cooktop burner.

During an interview on 1/7/25 at 12:20 P.M., the Food Service Director replaced the fridge thermometers and said that the food log should not have been filled out ahead of time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 225394