**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of adaptive equipment (a double handled mug) for beverages due to hand tremors, as well as staff assistance with set-up for meals, the Facility failed to ensure he/she received adequate staff assistance during meal service related to the nurses' inspection of meal trays for appropriateness of the meal, as well as for the inclusion of necessary adaptive equipment per each resident's meal ticket, prior to the meal tray being delivered and served to the resident, in an effort to prevent an incident/accident resulting in an injury. On 03/30/24, Resident #1's dinner tray was not checked by nursing prior to being served as required, the tray did not include his/her required double handled mug and his/her hot beverage was served in a Styrofoam cup. Resident #1 spilled the hot beverage on his/her thigh, which resulted in him/her sustaining a second degree burn (a partial thickness burn that affects the first and second layers of skin), which required treatment. Findings include: Review of the (undated) Facility Policy titled Food Tray Accuracy and Delivery, indicated the following: -A licensed nurse or qualified designee will check each resident tray prior to distributing to the resident to ensure that the name and room number of the resident are accurate and verify that the items on the plate or tray match the meal ticket for accuracy of the ordered diet, allergies and necessary adaptive equipment. -If the meal tray is missing necessary equipment the member of the nursing department or qualified professional will report it to the Food Service Manager so that the missing items can be provided prior to distributing the resident tray. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 04/05/24, indicated that on 03/30/24, Resident #1 was served his/her dinner, which included hot coffee, with paper products (Styrofoam cups) instead of his/her double handled mug. Resident #1 spilled the hot coffee on his/her left thigh and sustained a (second degree) burn which was deep pink with blisters at the edges. Review of the Investigation Report Form, dated 03/30/24 at 7:47 P.M., indicated that Resident #1 accidentally spilled hot coffee on his/her left thigh when he/she poured coffee from one cup (Styrofoam cup) to another cup and his/her hands were shaking. The Investigation indicated that Resident #1 did not report the incident immediately (instead waited approximately two hours). Resident #1 was admitted to the Facility in July 2023, diagnoses included Parkinsonism (an umbrella term that refers to brain conditions that cause tremors, slow movements, stiffness and rigidity) and diabetes mellitus with polyneuropathy (causes decreased sensation). Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/09/24, indicated he/she scored a 15 out of 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). The MDS also indicated he/she required staff assistance for meal set-up. Review of Resident #1's meal ticket (in place at time of incident on 03/30/24), indicated it included his/her name, diet, preferences and that he/she required adaptive equipment, a two handled covered mug. Review of Resident #1's Nutrition Care Plan, with goal date of 07/09/24, indicated he/she required a double handled mug with a spout. During an interview on 04/25/24 at 1:20 P.M., [NAME] #1 said she was on duty on 03/30/24 for the second shift (11:30 A.M. through 8:00 P.M.) and the kitchen was short staffed. [NAME] #1 said she called the Food Service Director (FSD) for instruction, and said the FSD told her to use paper products for the dinner meal (instead of regular plates, silverware, mugs etc). Cook #1 said that at that time (03/30/24), she was unaware that resident specific adaptive equipment was to be provided even when the Facility implemented the use of paper products instead of regular dishware. [NAME] #1 said that no resident specific adaptive equipment was provided to the residents during the dinner meal on 03/30/24. During an interview on 04/25/24 at 1:35 P.M., the Food Service Director (FSD) said that he instructed [NAME] #1 to use paper products for the dinner meal on 03/30/24. The FSD said that resident specific adaptive equipment should still be provided to residents who require it, even when the Facility chooses to use paper products instead of regular dishware. The FSD said Resident #1 required a two handled mug for beverages, however for the dinner meal on 03/30/24, he/she was provided a Styrofoam cup for his/her hot coffee. During an interview on 04/25/24 at 1:58 P.M., Nurse #1 said she was on duty for the 3:00 P.M. to 11:00 P.M. shift on 03/30/24. Nurse #1 said she did not check the resident's dinner meal trays for accuracy of diets, texture, or adaptive equipment, prior to the meals being distributed to the residents that night. Nurse #1 said she had not been trained to do so and at that time (03/30/24) she was unaware that it was nursing's responsibility. Nurse #1 said that Resident #1 reported, a couple hours (exact time unknown) after dinner, that he/she spilled hot coffee on his/her left thigh during dinner. Nurse #1 said she provided first aid, notified the Nurse Practitioner to obtain treatment orders, and also notified the Director of Nurses. Nurse #1 said the skin on Resident #1's left thigh was deep red with blisters forming at the edges. Review of Resident #1's physician's orders indicated he/she had a new order, dated 3/30/24, for Silvadene Cream 1% (topical antibiotic used for burns) to be applied to his/her left thigh burn twice daily. During an interview on 04/25/24 at 2:42 P.M., Certified Nurse Aide (CNA) #1 said Resident #1 was on her assignment on 03/30/24 for the 3:00 P.M. to 11:00 P.M. shift. CNA #1 said she delivered Resident #1's tray to him/her and said although she knew Resident #1 required a two handled mug for beverages, he/she instead was provided a Styrofoam cup for hot coffee. CNA #1 said she had not seen the nurse(s) check the resident dinner trays (for accuracy) on 03/30/24, prior to the CNA's delivering them that night. Review of Resident #1's care [NAME] (in place at time of incident on 03/30/24, used by Certified Nurse Aides to determine individual care needs) indicated he/she required a doubled handled mug with spout. During an interview on 04/25/24 at 3:34 P.M., the Director of Nurses (DON) said that the nurse(s) on the unit should have checked each resident's meal tray for accuracy prior to the meal tray being provided to a resident. The DON said that on 03/30/24, the nurse(s) should have notified kitchen staff that Resident #1 did not have his/her double handled mug on his/her dinner meal tray. On 04/25/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addresses the areas of concern as evidenced by: A) 03/30/24, Resident #1 was assessed by nursing, new orders were obtained for Silvadene Cream 1% (topical antibiotic used for burns) to be applied to his/her left thigh burn twice daily. B) 04/01/24 through 04/07/24, the Assistant Director of Nurses educated all licensed staff that nurses must check meal trays for correct diet consistency and adaptive equipment prior to the trays being given to the residents. C) 04/01/24 through 04/07/24, the Assistant Director of Nurses educated all licensed staff that when delivering residents meal trays, staff must offer to assist residents with setting up their tray such as opening cartons, cutting food, and pouring drinks. D) 04/01/24 through 04/09/24, the Food Service Director and Kitchen Manager educated the dietary staff on providing adaptive equipment to residents even when using Styrofoam and paper products. E) 04/03/24, the Food Service Director and the Administrator began an audit visualizing adaptive equipment against each resident's meal ticket on the resident's meal trays. F) 04/10/24, weekly audits were initiated related to adaptive equipment use and meal tickets, audits will continue times four weeks, then monthly times three weeks, will be conducted by the Administrator, Food Service Director, Food Service Manager, Assistant Director of Therapy, Therapy Assistants, Unit Nurse Managers and Nursing Shift Supervisors. G) The results of the weekly audits will be brought to Quality Assurance Performance Improvement (QAPI) monthly times three months or until substantial compliance is achieved. H) The Director of Nurses and/or designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Advanced Directives and Physician's Order indicated his/her elected code status was Do Not Resuscitate (DNR, medical order written by a physician, which instructs healthcare providers not to do cardiopulmonary resuscitation, in the event of cardiac or respiratory arrest) the Facility failed to ensure nursing staff honored his/her right to self-determination related to his/her choice of Advanced Directives. On [DATE], at approximately 8:30 A.M., Resident #1 was found unresponsive, was assessed by nursing to be without a pulse or respirations, and without verifying his/her code status, nursing staff immediately intervened and initiated life saving measures including starting chest compressions for CPR and activating the 911. Nursing then determined Resident #1 was a DNR and CPR was stopped, however Resident #1 had been resuscitated. Resident #1 was transferred to the Hospital Emergency Department, was diagnosed with 6th and 7th right rib fractures, as well as a second degree heart block, was admitted to the Hospital for four days, and then returned to the Facility. Findings include: The Facility Policy, titled Resident Rights and Responsibilities Guidelines, dated [DATE], indicated staff would uphold the residents' right to self-determination. The Facility Policy, titled Advance Directives, dated [DATE], indicated the Facility would honor the advance directives of the resident or their legal representative according to state and federal laws, guidelines, and regulations, and defined the following: -Advanced Directive was defined as a written instruction, recognized by State law, relating to the provisions of health care when the individual is incapacitated. -Do Not Resuscitate indicated that, in the case of respiratory or cardiac failure, the resident or representative has directed that no cardiopulmonary resuscitation (CPR) or other life saving methods were to be used. The Facility Policy, titled Do Not Resuscitate Guideline, dated 11/2020, indicated the Facility would honor a resident's right to withhold Cardiopulmonary Resuscitation and related emergency measures to maintain life functions when there was a Do Not Resuscitate order in effect. The Facility Policy, titled Cardiopulmonary Resuscitation (CPR) Guideline, dated [DATE], indicated Licensed Nurses and other designated staff were educated to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place. Resident #1 was admitted to the Facility in [DATE], diagnoses included dementia, malignant neoplasm of the brain, and bone density disorder. Review of Resident #1's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) Form, dated and signed by Resident #1 on [DATE], indicated he/she was a Do Not Resuscitate (DNR), Do Not Intubate (DNI), and to transfer to the Hospital. Review of Resident #1's Advance Directives Care Plan, dated [DATE], indicated he/she had Advanced Directives and they would be honored by staff. Review of Resident #1's Physician's Order, dated [DATE], (related to his/her Advanced Directives) indicated nursing staff were to refer to his/her MOLST. Review of the Nurse Progress Note, dated [DATE], indicated Resident #1 was found to be unresponsive sitting in his/her room in his/her wheelchair, a code blue was called, and he/she was transferred to the Hospital Emergency Department. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #1 was admitted to the Hospital via the emergency room on [DATE], was diagnosed with a second-degree heart block and 6th and 7th right rib fractures. Review of Unit Manager #1's Written Witness Statement, undated, indicated she was alerted that Resident #1 was unresponsive, and did not have a palpable pulse. The Statement indicated staff assisted Resident #1 to bed, at which time she (Unit Manager #1) initiated CPR (administered chest compressions) while another nurse checked Resident #1's chart for his/her code status, it was discovered that he/she was a DNR/DNI, and she stopped CPR. During interview on [DATE] at 10:16 A.M., Unit Manager #1 said that on [DATE] at 8:30 A.M., she was alerted by a Certified Nurse Aide that Resident #1 was unresponsive. Unit Manager #1 said she ran to Resident #1's room, saw that he/she was slumped over in his/her wheelchair, was limp, pale, had no observable respirations, and she could not feel a radial (wrist) pulse. Unit Manager #1 said she instructed staff to transfer Resident #1 to his/her bed, to call a code blue, and asked what his/her code status was, to no one in particular. Unit Manager #1 said once Resident #1 was in bed, she checked again for respirations and a radial pulse, and when she assessed that he/she had neither, she administered 30 chest compressions. Unit Manager #1 said that right when she completed the 30 chest compressions, someone yelled out that Resident #1 was a DNR. Unit Manager #1 said she stopped doing chest compressions and that Resident #1 became responsive, pushed her hand away, and was talking in a low voice. Unit Manager #1 said she thought the protocol was to initiate CPR and then stop if it was discovered that a resident was a DNR. Unit Manager #1 said she felt afterwards as though she had not honored Resident #1's wishes to be a DNR, and said she felt bad that he/she had fractured ribs as a result of the chest compressions. During interview on [DATE] at 11:56 A.M., the Director of Nurses (DON) said that on [DATE], she responded to the overhead code blue page, and when she arrived at Resident #1's room, he/she was unresponsive in his/her wheelchair, staff transferred him/her to bed, and Unit Manager #1 administered chest compressions. The DON said soon after chest compressions were started, someone yelled that Resident #1 was a DNR, chest compressions were stopped, and Resident #1 was observed to be responsive at that time. The DON said Resident #1 was then transferred to the Hospital emergency room via 911. The DON said chest compressions should not have been performed on Resident #1 as he/she had Advance Directives in place and a signed MOLST which indicated he/she was a DNR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Comprehensive Person Centered Plan of Care indicated staff were to honor his/her Advance Directives, which indicated he/she was a Do Not Resuscitate (DNR, medical order written by a physician, it instructs healthcare providers not to do cardiopulmonary resuscitation in the event of cardiac or respiratory arrest), the Facility failed to ensure the staff implemented and followed interventions identified in his/her plan of care related to his/her Advanced Directives, when on [DATE], at approximately 8:30 A.M., after being found unresponsive, and assessed by nursing to be without a pulse or respirations, nursing staff immediately intervened and initiated Cardiopulmonary Resuscitation (CPR) in an attempt to resuscitate him/her, and activated the 911, without first verifying his/her code status. Resident #1 was resuscitated by nursing, was transferred to the Hospital Emergency Department for evaluation, was diagnosed with 6th and 7th right rib fractures, as well as second degree heart block, was admitted to the Hospital for four days, and then returned to the Facility. Findings include: The Facility policy, titled, Care Plan Guideline, dated [DATE], indicated the Facility would develop an individualized plan of care for each resident, and staff were responsible for implementation of the plan. The Facility Policy, titled Advance Directives, dated [DATE], indicated the Facility would honor the advance directives of the resident or their legal representative according to state and federal laws, guidelines, and regulations, and defined the following: -Do Not Resuscitate indicated that, in the case of respiratory or cardiac failure, the resident or representative has directed that no cardiopulmonary resuscitation (CPR) or other life saving methods were to be used. Resident #1 was admitted to the Facility in [DATE], diagnoses included dementia, malignant neoplasm of the brain, and bone density disorder. Review of Resident #1's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) Form, dated and signed by Resident #1 on [DATE], indicated he/she was a Do Not Resuscitate (DNR), Do Not Intubate (DNI), and to transfer to the Hospital. Review of Resident #1's Advance Directives Care Plan, dated [DATE], indicated he/she had Advanced Directives and they would be honored by staff. Review of Resident #1's Physician's Order, dated [DATE], (related to his/her Advanced Directives) indicated nursing staff were to refer to his/her MOLST. Review of the Nurse Progress Note, dated [DATE], indicated Resident #1 was found to be unresponsive sitting in his/her room in his/her wheelchair, a code blue was called, and he/she was transferred to the Hospital Emergency Department. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #1 was admitted to the Hospital via the emergency room on [DATE], was diagnosed with a second-degree heart block and 6th and 7th right rib fractures. Review of Unit Manager #1's Written Witness Statement, undated, indicated she was alerted that Resident #1 was unresponsive, and did not have a palpable pulse. The Statement indicated staff assisted Resident #1 to bed, at which time she (Unit Manager #1) initiated CPR (administered chest compression) while another nurse checked Resident #1's chart for his/her code status, it was discovered that he/she was a DNR/DNI, and she (Unit Manager #1) stopped CPR. During interview on [DATE] at 10:16 A.M., Unit Manager #1 said that on [DATE] at 8:30 A.M., she was alerted by a Certified Nurse Aide that Resident #1 was unresponsive. Unit Manager #1 said she ran to Resident #1's room, saw that he/she was slumped over in his/her wheelchair, was limp, pale, had no observable respirations, and she could not feel a radial (wrist) pulse. Unit Manager #1 said she instructed staff to transfer Resident #1 to his/her bed, to call a code blue, and asked what his/her code status was, to no one in particular. Unit Manager #1 said once Resident #1 was in bed, she checked again for respirations and a radial pulse, and when she assessed that he/she had neither, she administered 30 chest compressions. Unit Manager #1 said that right when she completed the 30 chest compressions, someone yelled out that Resident #1 was a DNR. Unit Manager #1 said she stopped doing chest compressions and that Resident #1 became responsive, pushed her hand away, and was talking in a low voice. During interview on [DATE] at 11:56 A.M., the Director of Nurses (DON) said that on [DATE], she responded to the overhead code blue page, and when she arrived at Resident #1's room, he/she was unresponsive in his/her wheelchair, staff transferred him/her to bed, and Unit Manager #1 began CPR and administered chest compressions. The DON said soon after chest compressions were started, someone yelled that Resident #1 was a DNR, chest compressions were stopped, but that Resident #1 was observed to be responsive. The DON said chest compressions should not have been performed on Resident #1 as his/her plan of care indicated he/she had Advance Directives in place and a signed MOLST which indicated he/she was a DNR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Advanced Directives indicated he/she was a Do Not Resuscitate (DNR, medical order written by a physician, it instructs healthcare providers not to do cardiopulmonary resuscitation in the event of cardiac or respiratory arrest), the Facility failed to ensure services provided by nursing met professional standards of practice, when nursing initiated life saving measures including performing Cardiopulmonary Resuscitation on a resident who was a DNR. On [DATE], at approximately 8:30 A.M., Resident #1, was found unresponsive, was assessed by nursing to be without a pulse or respirations, and nursing immediately intervened and initiated life saving measures in an attempt to resuscitate him/her, including starting CPR (administering chest compressions) and activating 911, without verifying his/her code status. Resident #1 was resuscitated, transferred to the Hospital Emergency Department for evaluation, was diagnosed with 6th and 7th rib rib fractures, as well as second degree heart block, was admitted to the Hospital for four days, and then returned to the Facility. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Titled Nursing Practice and Cardiopulmonary Resuscitation, dated as revised 12/2018, indicated that as a Standard of Nursing Practice, the nurse licensed by the Board is expected to engage in the practice of nursing in accordance with accepted standards of practice. It is the Board's position that these standards, in the context of practice in all settings where health care is delivered require initiating cardiopulmonary resuscitation when a patient has been found unresponsive and has not yet been declared dead by a provider authorized pursuant to M.G.L. c. 46, § 9, except when the patient has a current, valid Do Not Resuscitate order/status. It further indicated, that for the purpose of this Advisory Ruling, the licensed nurse must, at a minimum, attain and maintain the following competencies through successful completion of entry-level nursing education programs or continuing education experiences, the nurse's role in obtaining accurate information about the DNR status of all assigned patients. The Facility Policy, titled Do Not Resuscitate Guideline, dated 11/2020, indicated the Facility would honor a resident's right to withhold Cardiopulmonary Resuscitation and related emergency measures to maintain life functions when there was a Do Not Resuscitate order in effect. The Facility Policy, titled Cardiopulmonary Resuscitation (CPR) Guideline, dated [DATE], indicated Licensed Nurses and other designated staff were educated to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place. Resident #1 was admitted to the Facility in [DATE], diagnoses included dementia, malignant neoplasm of the brain, and bone density disorder. Review of Resident #1's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) Form, dated and signed by Resident #1 on [DATE], indicated he/she was a Do Not Resuscitate (DNR), Do Not Intubate (DNI), and to transfer to the Hospital. Review of Resident #1's Advance Directives Care Plan, dated [DATE], indicated he/she had Advanced Directives and they would be honored by staff. Review of Resident #1's Physician's Order, dated [DATE], (related to his/her Advanced Directives) indicated nursing staff were to refer to his/her MOLST. Review of the Nurse Progress Note, dated [DATE], indicated Resident #1 was found to be unresponsive sitting in his/her room in his/her wheelchair, a code blue was called, and he/she was transferred to the Hospital Emergency Department. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #1 was admitted to the Hospital via the emergency room on [DATE], was diagnosed with a second-degree heart block and 6th and 7th right rib fractures. Review of Unit Manager #1's Written Witness Statement, undated, indicated she was alerted that Resident #1 was unresponsive, and did not have a palpable pulse. The Statement indicated staff assisted Resident #1 to bed, at which time she (Unit Manager #1) initiated CPR (administered chest compression) while another nurse checked Resident #1's chart for his/her code status, it was discovered that he/she was a DNR/DNI, and she (Unit Manager #1) stopped CPR. During interview on [DATE] at 10:16 A.M., Unit Manager #1 said that on [DATE] at 8:30 A.M., she was alerted by a Certified Nurse Aide that Resident #1 was unresponsive. Unit Manager #1 said she ran to Resident #1's room, saw that he/she was slumped over in his/her wheelchair, was limp, pale, had no observable respirations, and she could not feel a radial (wrist) pulse. Unit Manager #1 said she instructed staff to transfer Resident #1 to his/her bed, to call a code blue, and asked what his/her code status was, to no one in particular. Unit Manager #1 said once Resident #1 was in bed, she checked again for respirations and a radial pulse, and when she assessed that he/she had neither, she administered 30 chest compressions. Unit Manager #1 said that right when she completed the 30 chest compressions, someone yelled out that Resident #1 was a DNR. Unit Manager #1 said she stopped doing chest compressions and that Resident #1 became responsive, pushed her hand away, and was talking in a low voice. Unit Manager #1 said she thought the protocol was to initiate CPR and stop it if it was discovered that a resident was a DNR. During interview on [DATE], Respiratory Therapist (RT) #1 said she was a certified Basic Life Support instructor, and said she conducted training for the staff at the Facility. RT #1 said the current standard of practice in a Long-Term Care Facility that staff were to check the resident's code status before administering any life saving measures including CPR and said that was what she taught facility staff during CPR trainings. RT #1 said nursing staff should not have administered chest compressions to Resident #1, as he/she had a valid MOLST that indicated he/she was a DNR. During interview on [DATE] at 11:56 A.M., the Director of Nurses (DON) said that on [DATE], she responded to the overhead code blue page, and when she arrived at Resident #1's room, he/she was unresponsive in his/her wheelchair, staff transferred him/her to bed, and Unit Manager #1 administered chest compressions. The DON said soon after chest compressions were started, someone yelled that Resident #1 was a DNR, chest compressions were stopped, and Resident #1 was observed to be responsive at that time. The DON said Resident #1 was then transferred to the Hospital Emergency Department via 911. The DON said that at the time of Resident #1's code blue, she misunderstood the current standard of practice and thought that staff were to begin CPR, and to discontinue it if a valid DNR order was discovered. The DON said that since that day, she was re-educated to the current standards of practice and said chest compressions should not have been performed on Resident #1 as he/she had Advance Directives in place and a signed MOLST which indicated he/she was a DNR.