Every finding on record at Alliance Health at Marie Esther

Based on record review, and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required, placing all facility residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse's Aides (CNA) that the RN was responsible for overseeing with provision of resident care.Specifically, the facility failed to have an RN working at least eight consecutive hours over a 24-hour period on three days (8/16/25, 8/30/25, and 8/31/25). Findings include:Review of the Facility Assessment Tool, last updated 7/23/25 and reviewed by the facilities Quality Assurance and Performance Improvement (QAPI) committee on 8/27/25, indicated:-How do we determine if we have sufficient staffing? Consider the following:>Review expectations for minimum staffing requirements at the federal and state level. >Federal law requires nursing homes to have sufficient staff to meet the needs of the Residents, to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. Review of the As Worked Nursing Schedule provided by the facility, failed to indicate that a Registered Nurse worked in the building for eight consecutive hours on 8/16/25, 8/30/25 and 8/31/25. During an interview on 9/4/25 at 2:20 P.M., the Assistant Administrator said that the Director of Nursing (DON) was providing RN coverage but was unable to provide evidence that the DON was in the building and providing eight consecutive hours of RN coverage on 8/16/25, 8/30/15 and 8/31/25. During an interview on 9/5/25 at 7:14 A.M., the Administrator said that the facility follows the federal regulation on RN coverage and that the facility does not have a policy pertaining to RN staffing.

Based on interview, and record reviews, the facility failed to offer the Pneumococcal Vaccination as recommended to two Residents (#2 and #22) of five applicable residents, out of a total sample of 12 residents, putting the Residents at risk for developing facility acquired Pneumonia.Specifically, the facility failed to ensure that:1. Resident #2 had no medical contraindication to, or had been offered, received, or declined any Pneumococcal Vaccination after admission to the facility.2. Resident #22 did not have medical contraindication to, or had been offered, received, or declined any Pneumococcal Vaccination after admission to the facility. Findings include: Review of the CDC guidance titled Pneumococcal Vaccine Recommendations, dated 10/26/24, indicated the following for individuals [AGE] years of age and older:-Administer PCV (Pneumococcal Conjugate Vaccine) 15 (Pneumococcal immunization that protects against 15 types of Pneumococcal disease), PCV20 (Pneumococcal immunization that protects against 20 types of Pneumococcal disease), or PCV21 (Pneumococcal immunization that protects against 21 types of Pneumococcal disease), for all adults 50 years or older:-Who have never received any Pneumococcal Conjugate Vaccine.-Whose previous vaccination history is unknown.-Give one dose of PCV20 or PCV21 at least 1 year after PCV13. Review of the facility policy titled Influenza and Pneumococcal Immunization, revised 3/28/25, indicated the following:-On admission, the resident and/or legal representative will be provided with written information regarding Pneumonia and Influenza Immunization.Residents will be encouraged to receive the vaccine.-Based on assessment and practitioner recommendation, adults aged 65 or older who have not previously received the pneumococcal vaccine or whose previous vaccination history is unknown should receive the appropriate pneumococcal vaccine based on the MD's assessment/order.-Subsequent documentation will be placed on the resident's individual Immunization Record. 1. Resident #2 was admitted to the facility in January 2023 and was over the age of 50. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident:-Was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of possible 15.-Resident's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) was invoked (put into effect).-Pneumococcal vaccination was up-to-date. Review of the Massachusetts Immunization Information System (MIIS) indicated Resident #2 received the Prevnar-13 (PCV13) Pneumococcal Vaccine on 5/25/16. Review of the CDC PneumoRecs VaxAdvisor online calculator indicated the following recommendation for Resident #2:-Give one dose of PCV20 or PCV21 at least 1 year after PCV13. During a telephone interview on 9/5/25 at 2:40 P.M., Resident Representative (RR) #1 said that he/she could not recall if the facility had offered a Pneumonia Vaccine for Resident #2, but that he/she would want an updated vaccine for the Resident if it were offered. Further review of Resident #2's medical record failed to indicate that the Resident had a medical contraindication to or had been offered, received, or declined a Pneumococcal Vaccination since admission to the facility in January 2023. 2. Resident #22 was admitted to the facility in July 2024 and was over the age of 50. Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident:-Was cognitively intact as evidenced by a BIMS score of 15 out of possible 15.-Pneumococcal vaccination was not up-to-date and had not been offered. Review of the Massachusetts Immunization Information System (MIIS) Vaccine Administration Record, provided by the facility indicated Resident #22 had a history of receiving an unspecified Pneumococcal Vaccine on 2/1/15. Review of the CDC PneumoRecs VaxAdvisor online calculator indicated the following recommendation for Resident #22:-Give one dose of PCV15, PCV20, or PCV21. If PCV20 or PCV21 is used, their pneumococcal vaccinations are complete. If PCV15 is used, follow with one dose of PPSV23 to complete their pneumococcal vaccinations. The recommended interval between PCV15 and PPSV23 is at least 1 year. During an interview on 9/5/25 at 1:18 P.M., Resident #22 said that he/she did not recall having any conversation with staff about Pneumonia Vaccination, that no staff had approached him/her to offer an updated vaccination, and he/she would want to receive an updated vaccine, if offered. Further review of Resident #22's medical record failed to indicate that the Resident had a medical contraindication to or had been offered, received, or declined a Pneumococcal Vaccination since his/her admission to the facility in July 2024. During an interview on 9/5/25 at 10:46 A.M., the Infection Preventionist (IP) said the facility process is to review resident's immunization history on admission to the facility and utilize the MIIS to review vaccination history, including Pneumococcal Vaccines, and then staff will offer updated vaccination consent forms which are kept in residents' medical record. During an interview on 9/5/25 at 2:21 P.M., the IP said she was unable to provide evidence that updated Pneumococcal Vaccinations were offered to Resident #2 or #22.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for food safety to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to utilize pasteurized eggs in the preparation of over easy (eggs fried on both sides with a runny yolk) eggs to safely accommodate the resident's choice during the breakfast meals and ensure that the unpasteurized eggs being used were cooked until all parts of the egg are completely firm to prevent the potential spread of foodborne illness. Findings include:Review of the facility's policy titled Food Purchasing, dated 9/1/25, indicated:-It is the policy.that all food be purchased from sources approved by Federal, State and local authorities. -Be knowledgeable of all the approved vendors. All food should adhere to the following standards.-Only Grade A eggs should be purchased. Frozen and packaged egg products shall be pasteurized. Review of the facility invoices from the facility vendor dated 6/24/25, 7/1/25, and 8/14/25, indicated that the eggs purchased to make the over easy eggs in the facility were not pasteurized. On 9/4/25 at 7:49 A.M., the surveyor observed the staff in the main kitchen serving breakfast onto nursing facility meal trays which included eggs cooked over easy. When the surveyor asked the Food Service Director (FSD) to observe the eggs that were being used to cook the over easy eggs, the eggs were observed to not be pasteurized. During an interview at the time, the FSD said that there were three Residents who typically request over easy eggs for breakfast. The FSD said that he was not aware that the eggs were required to be pasteurized for egg dishes that are not fully cooked.

Based on observation, interview, and record review, the facility failed to ensure that medications were stored in a safe and secure manner for one Resident (#22) out of a total sample of 12 residents.Specifically, for Resident #22, the facility failed to ensure that:-One over-the-counter medication was secured and was not left at the Resident's bedside table and readily accessible to other residents on the unit.-One prescribed medication was secured and was not left at the Resident's bedside table and readily accessible to other residents on the unit.- A Physician's order was obtained for the use of one over-the-counter and one prescribed medication.- A self-assessment of medication was completed to ensure the Resident was capable of self-administering medications. Findings include: Review of the facility policy titled Medication Storage in the Facility, undated, indicated:-Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications.-Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of the facility policy titled Medication: Self Administration, revised 5/22/19, included but was not limited to:>Residents may administer their own medications, if requested, once the interdisciplinary team (IDT) determines that this practice is safe.>The resident must meet the following criteria:-The resident must be able to read the administration label on all medications.-The resident must be able to demonstrate an ability to dispense the medication from the receptable.-The resident must pass the Self-Administration Medication Assessment.-The resident must request the desire to self-administer medications.-Once the request is obtained, the above assessment must be completed with results documented in the medical record. This assessment is updated on a Qtrly (quarterly) basis.-Documentation of the administered drugs, and location of the administered drugs will be noted in the resident's care plan.-If the results indicate the person is capable of self-administration, the physician must be notified to obtain an order for such.-Medication must remain secured at the nursing station except for limited medications, i.e. (that is) respiratory (handheld) inhalers, nitroglycerin sublingual tablets or sprays. Medications must be stored under proper conditions of sanitation, temperature, light, moisture and ventilation.>Nursing remains responsible for:-Assuring the medication is taken.-Signing off medication order,-Monitoring for effects and side effects; and,-Notifying the physician of any changes in condition that might necessitate medication adjustment.>Self-administration of medication should be addressed in the care plan with an established plan for continuing to monitor ability to self-administer drugs and needs for continued education on an ongoing basis, including reliability in following the program and a reassessment of functional ability. Education includes the resident's and family's responsibilities in the resident care and how to safely and effectively use medication. The interdisciplinary team may withdraw right to self-administration if resident becomes unable to carry out safely. Resident #22 was admitted to the facility in July 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), and Age-Related Cognitive Decline. Review of Resident #22's Minimum Data Set (MDS) assessment, dated 7/7/25, indicated that the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 9/4/25 at 9:06 A.M., the surveyor observed Resident #22 was awake and seated at the edge of his/bed. The surveyor further observed the following medications located on the Resident's nightstand table:-Antifungal Powder with Miconazole Nitrate 2%-Thera Breath Dentist Formulated Fresh Breath Oral RinseDuring an interview at the time, Resident #22 said the Antifungal Powder with Miconazole Nitrate 2% and the Thera Breath Dentist Formulated Fresh Breath Oral Rinse were medications he/she had been using for over a year. Resident #22 said that he/she could administer the medications on his/her own and does not require nursing assistance to administer. Review of Resident #22's Physician orders failed to indicate any evidence that an antifungal powder and oral rinse had been ordered by the Physician for Resident #22. On 9/4/25 at 10:32 A.M., the surveyor and Nurse #1 observed the antifungal and oral rinse medications on Resident #22's nightstand table. During an interview at the time, Resident #22 said he/she uses the antifungal powder on a cut on top of his/her right thigh and that the antifungal powder was given to him/her by the wound doctor and he/she had been using it for a year without staff saying anything to him/her. Resident #22 said he/she did not believe a Doctor's order was required to have the oral rinse by his/her bedside. During an interview following the observation, Nurse #1 said Resident #22 was not allowed to keep/or have prescription medications at his/her bedside. Nurse #1 said she does not know the risk of Resident #22 having medications at the bedside as it was not a practice that was allowed in the facility. During an interview on 9/4/25 at 10:47 A.M., the Director of Nursing (DON) said Resident #22 was not allowed to have prescribed medications on his/her nightstand table for safety reasons. The DON said the facility should have obtained a Physician's order to administer the antifungal powder and oral rinse medications. The DON also said that a self-assessment for medication should have been completed for Resident #22 to determine if the Resident was capable of self-administering medications for him/herself. The surveyor and the DON reviewed Resident #22 clinical records and failed to find evidence that a medication self-assessment was completed for Resident #22. During an interview on 9/4/25 at 11:11 A.M., Nurse #2 said Resident #22's Oral Rinse was an over-the-counter medication, and the Resident does not require a Doctor's order to administer the oral rinse. When the surveyor asked Nurse #2 if the facility policy requires a Resident to have over-the-counter oral rinse at their bedside without a Physician order and/or self-administration medication assessment, Nurse #2 said no.

Based on observation, interview, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice were provided for one Resident (#1) out of a total sample of 12 residents.Specifically, for Resident #1, the facility failed to provide portable oxygen as ordered by the Physician when the Resident was out of bed (OOB) and participating in activities away from the stationary oxygen source. Findings include: Review of facility policy, titled Physician Orders, effective 11/22/16 and revised 11/14/22, include but are not limited to:>it is the policy of the facility that a physician personally approves in writing a recommendation that an individual be admitted to the facility. Each resident will remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist can provide orders for the resident's immediate care and needs.-Medical Doctor (MD) orders will be followed by staff as appropriate until the order has been discontinued or changed. Resident #1 was admitted to the facility in April 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Bronchitis, not specified as Acute or Chronic, and Chronic Respiratory Failure with Hypoxia. Review of the Minimum Data Set (MDS) Assessment, dated 7/11/25, indicated Resident #1:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of total possible score of 15. -was prescribed continuous oxygen therapy. Review of Resident #1's Physician's orders indicated:-O2 (oxygen) at 2 LPM (liters per minute) via Nasal Cannula (NC) continuously for COPD every shift: Days (7:00 A.M.- 3:00 P.M.) Evening (3:00 P.M.-11:00 P.M.), Nights (11:00 P.M. - 7:00 A.M.), initiated 7/8/25.-Portable O2 use while OOB (out of bed) via Nasal Cannula every shift, initiated 7/8/25. Review of Resident #1's Comprehensive Person-Centered Care Plan revised 7/8/25, indicated:-the Resident has potential for respiratory distress related to a dx (diagnosis) of COPD and requires the use of oxygen.-intervention for oxygen as ordered. On 9/3/25 at 4:28 P.M., the surveyor observed Resident #1 lying in bed with the head of the bed elevated, with O2 via NC set to 2 LPM in use. During an interview at the time, Resident #1 said that he/she always uses oxygen. On 9/4/25 at 8:33 A.M., the surveyor observed Resident #1 in the main dining room on the unit eating his/her breakfast. The surveyor failed to observe that portable oxygen was observed being administered to the Resident at the time. On 9/4/25 at 8:50 A.M., the surveyor observed Resident #1 in the main dining room sitting in a wheelchair and participating in an activity. The surveyor observed that Resident #1 was not being administered portable oxygen as ordered during the activity session. On 9/4/25 at 10:19 A.M., the surveyor observed Resident #1 seated in a wheelchair in the main dining room without portable oxygen being administered. During an interview at the time, Resident #1 said he/she always uses oxygen. Resident #1 said he/she was dressed up by the Certified Nurse Aide (CNA) and the CNA took off the oxygen tubing/nasal cannula and did not put it back on. Resident #1 asked the surveyor to find out where his/her oxygen was and to get his/her oxygen for him/her. During an interview on 9/4/25 at 10:21 A.M., Nurse #1 said Resident #1 should always have his/her portable oxygen administered via NC as ordered by the Physician. Nurse #1 said Resident #1's oxygen had been removed when the CNA assisted him/her with getting dressed. Nurse #1 said Resident #1 should have his/her portable oxygen on continuously when out of his/her room. Nurse #1 said the risk of Resident #1 not having access to his/her oxygen as ordered was shortness of breath as the oxygen ensures that Resident #1 was able to breathe. During an interview on 9/4/25 at 10:49 A.M., the Director of Nursing (DON) said Resident #1 required his/her oxygen to be applied continuously as ordered by the Physician. The DON said she had seen Resident #1 with his/her oxygen in use on previous days. The DON said the risk of Resident #1 not having his/her oxygen applied as ordered would cause the Resident's oxygen levels to desaturate (decrease in the oxygen saturation) leading to shortness of breath for Resident #1.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff for care, the Facility failed to ensure he/she was free from physical abuse from a staff member when on 09/09/23, Resident #1 became combative during care and Certified Nurse Aide (CNA) #1 in response to Resident #1's behavior, hit Resident #1 on the top of his/her right hand, the incident was witnessed by CNA #2 and CNA #3, who were present and also assisted CNA #1 with Resident #1 at the time of the incident. A cognitively intact person would experience pain and mental anguish after being hit by a caregiver. Findings include: Review of the Facility's Policy titled Abuse Prohibition, dated as revised 10/11/22, indicated the following: -the Facility will provide an environment in which the resident is free from abuse, neglect, mistreatments, misappropriation of resident property, or exploitation, including but not limited to freedom from corporal punishment, involuntary seclusion, and any physical and chemical restraint that is not required to treat the resident's medical symptoms; -abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, or assault and battery; -physical abuse is hitting, slapping, pinching, kicking and control of behavior through corporal punishment, and -the Facility assumes the responsibility of ensuring the safety and well-being of the residents in their care. Staff are trained and knowledgeable in how to react and respond appropriately to resident behavior. Staff are expected to to respond appropriately and professionally to resident behaviors. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 09/09/23, indicated that on 09/09/23 at approximately 2:25 P.M., a CNA (later identified as CNA #2) reported to the Director of Nurses (DON) that another CNA (later identified as CNA #1) hit Resident #1's right hand while providing care. Review of the Facility's Investigation Summary, dated 09/09/23, indicated that on 09/09/23 at 2:25 P.M., CNA #2 reported that she saw CNA #1 hit Resident #1 while providing care in his/her bathroom. The Summary indicated that the Director of Nurses (DON) interviewed CNA #2 and she (CNA #2) told her it was not a tap, and that CNA #1 hit Resident #1 because he/she was being resistive and combative with care. The Summary indicated that the DON also interviewed CNA #3 and she told the DON that she was assisting CNA #1 with Resident #1's care in his/her bathroom and that Resident #1 was combative and pushed CNA #1 away. The Summary indicated that CNA #3 told the DON that CNA #1 took Resident #1's right hand and hit it, stating, no. The Summary indicated that CNA #1 told the DON that Resident #1 was pushing her away and hitting her. The Summary indicated that CNA #1 motioned that she took Resident #1's hand, hit it, and said no. Resident #1 was admitted to the Facility in December 2020, diagnoses included Alzheimer's disease, adjustment disorder with depressed mood, psychotic disorder with delusions, and anxiety disorder. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 08/28/23, indicated that he/she had severe cognitive impairment and required extensive assistance from one staff member for hygiene and bathing, and was dependent on two staff members for toileting. Review of Resident #1's Behavior Care Plan, dated 10/13/22, indicated the following interventions: -maintain a calm environment and approach to the resident, and -if resident has verbal or physical outbursts, assess, maintain safety and reapproach. Review of CNA #1's Written Witness Statement/Interview, dated 09/09/23, indicated that Resident #1 hit her when she was changing him/her. The Statement/Interview indicated that CNA #1 took Resident #1's hand and hit it back and said no. The Statement indicated that CNA #1 gestured taking a hand and hitting it with hers. The Statement/Interview indicated that the Director of Nurses (DON) told CNA #1 that this was abuse and requested that she leave the Facility. The Surveyor was unable to interview CNA #1 as she did not respond to the Department of Public Health's telephone call or letter request for an interview. During an interview on 09/28/23 at 12:11 P.M., and review of Certified Nurse Aide (CNA) #2's Written Witness Statement, dated 09/09/23, CNA #2 said that at approximately 2:00 P.M., she heard Resident #1 screaming, so she went to his/her room to help. CNA #2 said that Resident #1 was in his/her bathroom with CNA #1 and CNA #3, and was very agitated, so she tried to calm Resident #1 down. CNA #2 said she, CNA #1, and CNA #3 dressed Resident #1 in his/her bathroom. CNA #2 said that CNA #1 became very impatient and forceful with Resident #1. CNA #2 said that she saw CNA #1 grab Resident #1's hand and hit the top of his/her hand. CNA #2 said it was not just a tap, and said she also heard a slapping noise when CNA #1 hit Resident #1's hand. CNA #2 said she told CNA #1 to leave the bathroom and said she and CNA #3 finished providing care to Resident #1. During an interview on 09/29/23 at 12:40 P.M., and review of Certified Nurse Aide (CNA) #3's Written Witness Statement, dated 09/09/23, CNA #3 said that at approximately 2:00 P.M., she and CNA #1 were providing care for Resident #1 in his/her bathroom. CNA #3 said Resident #1 became combative, and then CNA #2 came to help them. CNA #3 said CNA #1 was being very impatient and forceful with Resident #1 and then Resident #1 hit CNA #1. CNA #3 said she saw CNA #1 hold Resident #1 by the wrist and forcefully hit the top of his/her hand. During an interview on 09/28/23 at 1:25 P.M., Nurse #1 said Resident #1 could be combative with care at times and said the CNAs should reapproach at a later time if this occurs. During an interview on 09/28/23 at 2:36 P.M., the Director of Nurses (DON) said that CNA #2 came to her on 09/09/23 sometime between 2:00 P.M. and 2:30 P.M. and told her that she saw CNA #1 hit Resident #1. The DON said CNA #2 told her that CNA #3 also witnessed the alleged potential abuse. The DON said she went to find CNA #1 who was on break, and said she asked CNA #1 to demonstrate what she did to Resident #1. The DON said CNA #1 demonstrated with her, using her hand how she (CNA #1) took Resident #1's hand and hit it the top of it. The DON said CNA #1 did not seem to think she had done anything wrong and said she had trouble removing CNA #1 from the Facility. The DON said that the Facility substantiated the allegation of physical abuse, and CNA #1 was no longer allowed in the Facility. Although Resident#1's impaired cognition minimized his/her understanding of the incident, an unimpaired individual would have experienced physical pain and mental anguish after being treated by a caregiver in this manner.

Based on observations, interviews and record review, the facility failed to ensure its staff provided appropriate treatment and services to maintain one Resident's (#25) comfort during dining, out of a total sample of 12 residents. Specifically, the facility failed to get Resident #25 out of bed for meals per preference, when the Resident required assistance from staff with transfers, and voiced concerns with choking and discomfort when eating while lying in bed. Finding include: Resident #25 was admitted to the facility in April 2022 with diagnoses including Fibromyalgia (chronic disorder characterized by widespread pain, fatigue, muscle stiffness and insomnia), Parkinsonism (brain condition that cause slowed movements, rigidity/stiffness and tremors), Traumatic Subdural Hemorrhage (condition where blood collects between the skull and the surface of the brain), Gastroesophageal Reflux Disease (GERD-chronic disease that occurs when stomach acid or bile flows into the food pipe and irritates the lining) and Irritable Bowel Syndrome (IBS-intestinal disorder causing pain in the belly, gas, diarrhea and constipation). Review of a Nurse's Note, dated 2/21/23, indicated Resident #25 called nursing staff into his/her room during breakfast stating that he/she choked on a prune pit and a Speech Language Pathologist (SLP) screen was submitted to evaluate his/her diet consistency for safety. Review of a Nurse's Note, dated 2/23/23, indicated that the SLP evaluated Resident #25 and made no diet texture/consistency changes. Review of the Minimum Data Set (MDS) Assessment, dated 3/13/23, indicated Resident #25 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of 15, had no behaviors or refusals of care, required total assistance from staff with bed mobility and transfers and was independent with eating. On 4/12/23 at 9:20 A.M., the surveyor observed Resident #25 lying in bed. The head of the bed was elevated and an overbed table with a hot beverage mug was positioned in front of him/her. The Resident was wearing a hospital gown and crumbs were observed on the front of the Resident's chest. During an interview at this time, Resident #25 said that he/she had asked the facility staff to be out of bed and to be seated up in the wheelchair for breakfast because he/she was concerned about choking. The Resident said that he/she was unable to reposition/boost him/herself and relied on facility staff to assist with this. Resident #25 said that he/she had asked and that nothing had been done about his/her request. On 4/13/23 at 9:14 A.M., Resident #25 was observed lying in bed with the head of the bed elevated. An overbed table with a hot beverage mug was positioned in front of him/her. During an interview at this time, Resident #25 said that he/she didn't know why breakfast was so difficult and felt it was due to having to eat while lying in bed. He/she said it was difficult to drink liquids while lying in bed and would prefer to sit up in his/her wheelchair for better positioning during meals. On 4/14/23 at 8:22 A.M., the surveyor observed Resident #25 lying in bed, eating from a breakfast tray that was on an overbed table positioned in front of him/her. The head of the bed was elevated, and the Resident was eating cereal from a container on his/her lap. During an interview at this time, Resident #25 said that he/she had to eat while reclined in bed, and had told the facility staff that he/she preferred to be up in the wheelchair for breakfast. Resident #25 said that it had been months since he/she had made this request, that his/her family had also raised the concern that it was difficult to eat while reclined in bed and that he/she was fearful of choking. Resident #25 said that when his/her concern had been raised to facility staff, he/she was told that they don't have enough staff to get him/her up, and because he/she was not a choking risk and able to eat by him/herself, they didn't have to get him/her out of bed for breakfast. During an interview on 4/14/23 at 8:25 A.M., Certified Nurse Aide (CNA) #2 said Resident #25 gets up out of bed after breakfast and staff breaks. CNA #2 said Resident #25 was not a choking risk and was able to eat while in bed. CNA #2 further said that there were other residents who request to be up for breakfast, but the staff were unable to accommodate due to all of the residents who are required to be up out of bed due to their feeding/swallowing ability. CNA #2 said that once the meals arrive on the unit, they were unable to provide resident care while the meals were being served. During an interview on 4/14/23 at 8:38 A.M., Rehabilitation Staff #1 said that she had worked with Resident #25 numerous times. She further said that there were eight residents who needed to be out of bed for meals and supervised, and that she has heard Resident #25 request to be out of bed for breakfast but because the Resident was independent with eating, he/she was able to eat in his/her room. During an interview on 4/14/23 at 8:49 A.M., Nurse #2 said Resident #25 requests to be up out of bed in the morning prior to breakfast but other residents have priority due to their risk of aspiration (accidentally breathing food/fluids into the airway) and need for increased supervision with meals. Nurse #2 said Resident #25 was independent with meals therefore could eat in his/her room. Nurse #2 also said there was a list of residents that the 11:00 P.M. to 7:00 A.M. staff assist with getting out of bed in the morning prior to breakfast, but Resident #25 was not included on that list. During an interview on 4/14/23 at 10:52 A.M., the surveyor spoke with Resident #25's family member, who said that she was aware of the Resident's ongoing concern. She said Resident #25 got up early in the morning and liked to be out of bed for breakfast because he/she was not comfortable eating reclined in bed. Resident #25's family member said there was an incident recently where he/she was eating breakfast in bed and almost choked on a pitted prune but was able to catch it. The family member said that she thought this incident made Resident #25 more nervous and that eating while lying in bed really affected him/her. The family member said that Resident #25 would like to be seated in his/her wheelchair or in the dining room for breakfast and that the facility staff had explained that there was not enough people to help with this due to the number of residents that were required to be up and out of bed based on their level of assistance/supervision with meals or choking risk, and that these residents take priority. She further said that Resident #25 was very uncomfortable eating while lying in bed, that he/she never ate meals that way and wanted to be up in a wheelchair for breakfast. The family member said that this concern had been brought up for over six months and had been discussed in the last two care plan conferences, but nothing had been done. Review of the Care Plan Conference Reports dated 10/19/22, 1/4/23 and 3/29/23, indicated meetings with the Resident, family member and interdisciplinary team were held, that areas were discussed and that all who participated were in agreement with the plan of care. There was no documented evidence of the specific details of what was discussed during the care plan meeting nor any issues/concerns that were identified. During an interview on 4/14/23 at 11:42 A.M., Social Worker (SW) #1 said that she oversees the care plan meeting process. SW #1 said that Resident #25, his/her family member and the interdisciplinary team attended the meetings. She said at the most recent care plan meeting a grievance was discussed about the Resident's concern about not getting up out of bed for breakfast. SW #1 said that an explanation was given to the Resident and his/her family that those on altered diets needed to be up and out of bed for breakfast and that Resident #25 was independent with eating. During an interview on 4/14/23 at 12:08 P.M., the Director of Nurses (DON) said Resident #25 was offered to get out of bed on the 11:00 P.M. to 7:00 A.M. shift, that this would occur around 4:00 A.M., and the Resident declined. The DON did not think that there was documentation to indicate this. The DON said that there were approximately eight residents that were required to be up for breakfast for safety reasons and also 17 residents who needed to be up to attend morning services for religious purposes. During an interview on 4/14/23 at 12:10 P.M., the Regional Nurse said that at 7:00 A.M., the facility had two to three CNAs to provide care. She said that the religious residents needed to be washed and dressed and up as well as the other residents who require supervision/assistance prior to breakfast, and that the facility followed a Per Patient Day (PPD- hours of scheduled nursing staff divided by the total number of residents) for staffing on the unit.

Based on record review and interview the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. Findings include: Review of the actual worked schedules from 11/6/21 through 11/30/21 indicated that on 11/6/21, 11/7/21, 11/20/21, 11/21/21, and 11/25/21 there were no RNs present at the facility in a 24 hour period. During an interview on 11/30/21 at 3:07 P.M., the Staff Development Coordinator/Infection Preventionist said that she did not believe there was an RN in the facility for 8 hours every day of the week. She said they only had licensed practical nurses (LPN) on the weekends, and sometimes they had an RN on one of the weekend days. During an interview on 11/30/21 at 4:07 P.M., the Director of Nurses said they had LPNs only, every other Saturday and Sunday, so one day per week there was no RN in the facility.

Based on interview and Quality Assurance and Performance Improvement (QAPI) meeting sign-in sheets, the facility failed to ensure the required members were present for one out of four quarterly meetings. Findings include: Review of the last four quarters of QAPI meeting sign-in sheets indicated the Director of Nurses (DON) was not present for the most recent meeting held on October 26, 2021. During an interview on 12/1/21 at 2:18 P.M., the administrator reviewed the October 26, 2021 sign-in sheet and said the DON was not in attendance and should have been. He said the DON was supposed to attend every QAPI meeting.

Based on observation, record review and interview, the facility failed to provide the necessary services to maintain grooming for one Resident (#14) in a total sample of 12 residents. Findings include: Resident #14 was admitted to the facility in April 2019. On 11/30/21 at 8:20 A.M., the surveyor observed Resident #14 sitting up in bed, eating breakfast, and he/she had noticeably long facial hair. Review of the Care Plan, updated 10/2021, indicated the Resident was dependent with grooming. Review of November 2021 Nursing Assistant Flow Sheets indicated the Resident required total dependent care for grooming tasks from the nursing assistants on the 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M. shifts. On 12/1/21 at 8:16 A.M., the surveyor observed Resident #14 sitting up in bed eating breakfast, and he/she still had noticeably long facial hair. On 12/1/21 at 10:25 A.M., the surveyor observed the Resident sitting in his/her wheelchair beside the bed. Resident #14 was dressed, his/her hair was brushed, however his/her facial hair was still long and appeared unchanged since the initial observation on the morning of 11/30/21. During an interview on 12/1/21 at 10:30 A.M., Nurse #1 said that the Resident's morning care was completed. When asked about the Resident's facial hair, the nurse said the Resident should have been shaved. The nurse asked Resident #14 if he/she would like to have his/her facial hair shaved, and the Resident said yes. The Resident then told the nurse that the razor was in the top drawer.

Based on record review and interview, the facility failed to accurately code a medication administered over the last 7 days on the Minimum Data Set (MDS) Assessment for one Resident (#231), out of a total sample of 12 residents. Findings include: Resident #231 was admitted to the facility in November 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -fracture of the left femur (the thigh bone of the upper leg) -surgical repair of the femur -history of stroke (poor blood flow to the brain) Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (A target specific oral anticoagulant medication used to treat and prevent blood clots and to prevent stroke) 2.5 milligrams (mg) give one tab (tablet) po (by mouth) 2 times a day. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 11/19/21, Section N titled Medications, indicated that no anticoagulant medication had been administered to the Resident beginning 11/12/21 through 11/18/21. During an interview on 12/1/21 at 10:39 A.M., the MDS nurse said that she had completed the MDS on 11/19/2021, and that she had not coded the [MEDICATION(S)] as an anticoagulant medication in Section N of the MDS assessment because she did not think it was an anticoagulant medication. During an interview on 12/1/21 at 12:38 P.M., the Staff Development/Infection Preventionist nurse said that she had never coded [MEDICATION(S)] as an anticoagulant, and it was her understanding that it was not required. Review of the MDS Resident Assessment Instrument (RAI) 3.0 Manual v1.17.1, October 2019, in reference to Section N0410-E: Medications Received, indicated but was not limited to: *N0410A-H: Code medications according to the pharmacological classification, not how they are being used. *N0410E, Anticoagulant (example: [MEDICATION(S)], [MEDICATION(S)], or low- molecular weight [MEDICATION(S)]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION(S)], or [MEDICATION(S)] here. *Anticoagulants such as Target Specific Oral Anticoagulants (TSOACs), which may or may not require laboratory monitoring, should be coded in N0410E, as an Anticoagulant. Review of the article titled Target-Specific Oral Anticoagulants published April 18, 2014 in the U.S. Pharmacist Journal, US Pharm. 2014;39(4):69-74, authors [NAME] and Shea, included [MEDICATION(S)] as a target specific oral anticoagulant.

Based on record review and interview the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) as required for two Residents (#131 and #132), out of two applicable sampled residents. Findings include: Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review indicated Resident #131 received Medicare Part A skilled services from 10/25/21 through 10/31/21. Further review indicated a NOMNC was not issued to the Resident or Resident Representative to inform him/her that skilled services were being discontinued. Review of the SNF Beneficiary Protection Notification Review indicated Resident #132 received Medicare Part A skilled services from 5/10/21 through 6/3/21. Further review indicated a NOMNC was not issued to the Resident or Resident Representative to inform him/her that skilled services were being discontinued. During an interview on 12/01/21 at 9:58 A.M., Social Worker (SW) #1 said she didn't have copies of either of the NOMNCs being issued. She said a notice was never issued and should have been. She said that they had an interim SW at the time and that may have been why they were missed.

Based on observation, policy review and interview, the facility failed to ensure that contaminated personal protective equipment (PPE) was disposed of properly to prevent the possible spread of COVID-19 on 1 of 1 nursing units. Findings include: During the entrance interview with the Administrator on [DATE] at 7:15 A.M., the Administrator said that Covid-19 negative residents and COVID-19 positive residents were kept separated on the nursing unit. Review of the form titled Facility Line Listing given by the facility to the surveyor, indicated that Resident #1 had died at the facility on [DATE] after having been diagnosed with [REDACTED]. On [DATE] at 8:17 A.M., the surveyor observed Funeral Home Staff (FH) #1 and FH #2 arrive on the nursing unit wearing masks. FH #1 and FH #2 donned (put on) gowns and faceshields and staff opened the secured doors to the COVID-19 positive area so they could obtain Resident #1's body. On [DATE] at 8:28 A.M., FH #1 and FH #2, with the assistance of Nurse #2, exited the COVID-19 unit with Resident #1's body on a stretcher and with the assistance of Nurse #2. FH#1 and FH#2 were both wearing the same blue gowns they had worn onto the unit and black gloves on each hand. FH #1 and FH #2 did not clean their faceshields. FH#1 pressed the button for the elevator with his gloved hand, therefore contaminating the button, and waited for the elevator to arrive. Nurse #1 then walked by and also pressed the button of elevator, therefore contaminating her hands. FH #1 and FH #2 entered the elevator (still wearing the PPE that was worn while transferring the body of a the COVID-19 positive resident onto a the stretcher, and while being in a COVID -19 positive area) and left the unit, therefore contaminating the elevator and all of the areas they would pass while in exiting the facility. During an interview on [DATE] at 8:33 A.M., Nurse #1 said that FH #1 and FH #2 should have taken off their PPE upon exiting the COVID-19 unit. Review of the facility's Infection Prevention Contact Precautions Policy, dated [DATE] indicated the following: Contact isolations requires at a minimum the following PPE - gloves and gown with interactions that may involved contact with the resident or potentially contaminated areas in the resident's environment. Donning/Doffing is done on entrance and exit to contain pathogens.

Based on observation and interview, the facility staff failed to provide a safe, functional environment for residents, staff and the public, related to mechanical equipment in the kitchen. Findings include: During interview on [DATE] at 11:32 A.M., the Food Service Director (FSD) stated there have been several issues with malfunctioning equipment, inability to keep food hot, ovens don't work properly, and either food gets burned or not fully cooked. The surveyor observed a single flame coming from the back, left burner of the stove. The flame was a bright orange color, and flickered at least ,[DATE] inches high from the burner (yellow or orange pilot light will produce carbon monoxide - an odorless, colorless gas, and cause carbon monoxide poisoning. Symptoms of this condition include dizziness, headache, fatigue and nausea). Cook #1 said that was the pilot light. Cook #1 placed a large rectangular pan on top of the stove. This pan covered the left front and back burners on the stove. Cook #1 turned both the front and back burners on high. The flames came up around the back of the rectangular pan. During interview on [DATE] at 7:00 A.M., Dietary Aide (DA) #3 said the alarms have gone off a lot lately, and the Fire Department (FD) had to come. DA #3 said that the steam unit went down recently, and had to be fixed, but is okay to use now. DA #3 said the ovens are weird .don't always work right. During the tray line observation on [DATE] at 11:15 A.M., the surveyor observed the pilot light flame flickered approximately ,[DATE] inches from the same back left burner. During interview on [DATE] at 1:10 P.M., the FSD said that the FD has been out to the facility multiple times since she has been here (,[DATE]), for various problems, such as natural gas system alarmed and carbon monoxide (CO2) detector alarm failures. The Surveyor asked the FSD if these events she is referring to had been remedied /tracked to ensure future concerns would not occur, such as mechanical breakdown related to the steam oven. The FSD said she recalled kitchen staff being nauseated, dizzy with headaches, and had to go outside. The surveyor asked the FSD if she reported these kitchen staff illnesses, or had any of them seek medical care, she said no. The FSD said every time the FD came, the Maintenance Department came as well, and they could probably give more information on mechanical/electrical problems in the kitchen. The FSD said she never documented these safety concerns. During interview on [DATE] at 1:30 P.M., Maintenance Staff (MS) #1 said the FD had been out to the facility on ly three times, over the past few months, that he can recall, and and not as the FSD identified. MS #1 said first, when the natural gas apparatus malfunctioned, it triggered an alarm at the FD. The FD responded and the problem was taken care of. MS #1 said the second time the carbon monoxide (CO2) alarm sounded, signaling at the FD, and this was taken care of as well, as the FD determined there was no CO2 leak. MS #1 said the third problem was the cover over the pilot light had turned on the stove, causing the pilot light to go out, but gas continued to flow from the mechanism where the pilot light was, causing a gas odor. MS #1 said all we had to do was turn the cover, open the area, and re-ignite the pilot light. The surveyor asked if they had instructed kitchen staff to ensure the cover did not turn when cleaning the stove, or to actually find out what the problem was, to ensure it did not occur again. MS #1 said he did not recall, and there was nothing documented by the Maintenance Department. MS #1 said he had to wait for invoices to come in on parts, repairs, then he could identify dates and times of occurrences. The surveyor then pointed out observations made on ,[DATE] and [DATE] when the pilot light flame was high, and bright orange on the back left burner to the stove. MS #1 said the flame should not be high, and should not be orange as this can mean the pilot light is clogged. During interview on [DATE] at 1:45 P.M., the Administrator, who said she was hired by the facility in ,[DATE], said she had just been made aware there was no follow-through, re-education/tracking to prevent ensure further mechanical problems did not occur with malfunctioning kitchen equipment, especially the natural gas and CO2 monitors, triggering alarms at the FD. The Administrator was not aware of routine maintenance on stoves, ovens etc., to prevent further problems.

Based on observation, document, policy review and interviews, the facility staff failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his/her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Findings include: During the initial kitchen observation on 6/13/19 at 8:30 A.M., the surveyor reviewed the temperature (Chef's Food Log) and foods served for the breakfast meal (Posted Menu), such as Chef's choice (pancakes), sausage/bacon (sausage patty), oatmeal, and scrambled eggs. There was a section where the cook would document what the food tasted like, and all areas were blank. Cook #1 said he recorded the temperatures, but did not taste the food. During interview, on 6/13/19 at 11:18 A.M., Resident #34 said food has gone down for the past 3 months .no more bananas on my tray for breakfast, and no scrambled eggs this morning .no oatmeal, as I usually have. The only thing I received was a small, thin thing they call a pancake, and a small, thin piece of sausage that was dry . I didn't get any milk for my tea .it's something different every day .and I don't like to complain. (The food served for breakfast were scrambled eggs and oatmeal, however, Resident #34 did not receive these, per her wishes 6/13/19 at 8:00 A.M.). During interview on 6/13/19 at 11:32 A.M., the Food Service Director (FSD) said Dietary Services are contracted, and they have been here since 4/2019. The FSD said the facility accused the contracted Dietary Service company staff of repetitive menus, foods that were alike, and with no color. The FSD said that there have been several issues with malfunctioning equipment, inability to keep food hot, ovens don't work properly, and either food gets burned or not fully cooked. Review of the 6/13/19 Lunch: Regular meal, posted for the residents on the Long Term Care (LTC) floor, indicated the following was planned: Salisbury steak; chicken tenders, sliced glazed carrots, seasoned whole kernel corn; Duchess mashed potatoes; buttered noodles; dinner rolls, fruit cocktail. On 6/13/19 at 11:38 A.M., the surveyor observed various sized chafing pans set inside a large rectangular baking pan on the stove, as follows: - Salisbury steak, were thin, appeared dry, as they were stacked on top of one another. - Ground/Pureed Salisbury steak. There was no evidence of pureed/ground chicken tenders. - Sliced carrots (not glazed) soaking in a solution. - Whole kernel corn. - Noodles. - Mashed. Cook #1 said the potatoes were not Duchess potatoes as on the planned menu. Cook #1 plated the food, as called out by the FSD. Cook #1 removed the top portion of a Salisbury steak patty from the top of the stack. (appeared dry, as the pan had not been covered until served. The surveyor observed as the FSD prepared the residents' trays, and called out for mashed potatoes, pureed Salisbury steak and no carrots. Cook #1 asked the FSD, should I just give noodles, then? The FSD said Yes. This unidentified resident's plate had the pureed steak, mashed potato and noodles. The surveyor asked what the alternate vegetable was. Cook #1 said it was corn, but wasn't sure if corn could be pureed, so he did not puree the alternate vegetable, and there was nothing else. During interview on 6/13/19 at 2:20 P.M., Resident #11 said the quality of the food has changed drastically over the past few months. Resident #11 said he/she cannot eat the mashed potatoes served here, and all he/she ate at lunch was the sliced carrots. The resident said the food is consistently cold, and that staff will microwave it to get it hot, but this takes away from the taste and texture of the food .dries it out too much. On 6/17/19 at 11:15 A.M., the surveyor arrived to the kitchen to observe the tray line, as part of conducting a test tray observation. The surveyor asked DA (Diet Aide) #4 to set up a test tray, with all foods/textures presented to residents. One test tray to be placed last on Food Truck #1 (Surveyor #1 would test), and instructed one test tray would be placed last, on Food Truck #2 (Surveyor #2 would test). Review of the Lunch-Regular meal to be served 6/17/19 consisted of open faced turkey sandwich; lemon pepper fish; whole kernel corn; seasoned zucchini; mashed potatoes; parsley rice, and deluxe fruit salad. The surveyor observed a pan that contained cut up pale, light green zucchini (no puree zucchini available). At 11:40 A.M., Cook #1 obtained a temperature of the lemon fish portions, and said he would put the fish into the steamer oven to bring the temperature up (temperature was 134.5 degrees F). The pan containing the fish portions had been stored in a warming cabinet, underneath the counter. At 11:47 A.M., Cook #1 removed the fish (temped now at 180 degrees F) from the steamer oven, he had placed earlier to reheat it, and placed the pan inside the rectangular pan which held 1/4 inch of water. At 11:52 A.M., DA #4 told Cook #1 that an unidentified resident disliked turkey and fish. The FSD made an egg salad sandwich, plated, and covered it, and handed it to DA #4. At 12:17 P.M., the surveyor observed Cook #1 remove the pan containing fish portions from the warming cabinet, underneath the counter, removed the plastic wrap, then placed one fish portion on the plate, along with other foods. Cook #1 left the pan of fish on the counter. At 12:21 P.M., Cook #1 plated a fish portion from the pan that was left on the counter, and not over a heat source to maintain proper temperatures. This pan continued to be stored on the metal counter. At 12:34 P.M., the last tray was served, and the test tray was obtained for testing by the Surveyor with the Regional FSD standing by to witness. The FSD arrived to the unit, and said she would take over observing as the surveyor obtained food temperatures and tasted food for palatability as follows: . Turkey slice: 133.7 degrees F. (gravy on it, was flavorful, but tepid). - Pureed turkey: 111.7 degrees F. (gravy on it, flavorful, but cool) - Ground turkey: 122.5 degrees F. (gravy on it, flavorful, but tepid) - Lemon Pepper fish: 135.6 (bland, no lemon or pepper flavor, dry and tepid) - Whole corn: 121.4 degrees F (not seasoned, tepid) - Pureed corn: 111 degrees F. (cool to taste, gummy, not palatable) - Seasoned zucchini: 119.6 degrees F (bland, not seasoned, tasteless, pale color and cool) - Mashed potatoes: 134.1 degrees F. (instant mashed, soupy, gritty, tepid, not palatable). The FSD asked if she could taste the potatoes, then proceeded to do so. The FSD said she agreed, the potatoes were not hot. She did not comment on the taste. - Milk: 54.3 degrees F. (not cold or palatable) - Coffee: 145: (tasted very warm). During discussion with the FSD, directly after the test tray, the FSD stated she has made every effort to ensure hot, palatable food had been served to the residents. The FSD said there have been on-going problems with cold food, food not being prepared, as instructed, and repetitive menus. The FSD said there was nothing else the FSD/staff could do to remedy the problem in the Kitchen. Please refer to F804 and F908.

Based on observation, document review and interviews, the facility staff failed to ensure each resident's food and drink was palatable, attractive, and at a safe and appetizing temperature, taking into consideration each resident's dietary and daily nutritional needs. Findings include: 1. Review of the Chef's Daily Log sheets, were as follows: 6/10/19: - Temperatures were not obtained for the walk-in freezer/cooler, milk cooler and reach-in cooler for the morning or afternoon timeframes, as directed/required. - Meal Temperatures and Tasting Panel section identified none of the foods served had been tasted by the Chef for all three meals, as directed. The lunch and dinner meals did not list milk/juice coffee as being served, and there was no temperature for any of these beverages recorded. - French toast had not been identified or temperature obtained. 6/11/19: - Temperatures were not obtained for the walk-in freezer/cooler, milk cooler and reach-in cooler for the morning or afternoon timeframes, as directed/required. - Meal Temperatures and Tasting Panel section identified none of the foods served had been tasted by the Chef for all three meals, as directed. The lunch and dinner meals did not list milk/juice/coffee as being served, and there was no temperature for any of these beverages recorded. 6/12/19: - Temperatures were not obtained for the walk-in freezer/cooler, milk cooler and reach-in cooler for the morning or afternoon timeframes, as directed/required. - Meal Temperatures and Tasting Panel section identified none of the foods served had been tasted by the Chef for all three meals, as directed. The lunch and dinner meals did not list milk/juice/coffee as being served, and there was no temperature for any of these beverages recorded. - Foods identified on the menu, were not identified as having temperatures taken, such as zucchini with onions and steamed rice. 2. During interview, on 6/13/19 at 11:18 A.M., Resident #34 said food has gone down for the past 3 months. The only thing I got was a small, thin thing they call a pancake, and a small, thin piece of sausage that was cold and dry . I didn't get any milk for my tea .it's something different every day .and I don't like to complain. Review of the 6/13/19 Lunch: Regular meal, posted for the residents on the LTC floor, indicated the following was planned: Salisbury steak, chicken tenders, sliced glazed carrots, seasoned whole kernel corn; Duchess mashed potatoes; buttered noodles; dinner rolls and fruit cocktail. On 6/13/19 at 11:38 A.M., the surveyor observed various sized chafing pans set inside a large rectangular baking pan on the stove, as follows: - Salisbury steak, were thin, appeared dry, as they were stacked on top of one another (temperature identified was 190 degrees Fahrenheit (F). - Ground/Pureed Salisbury steak (Temperature identified as being 185 degrees F. There was no evidence of pureed/ground chicken tenders. - Sliced carrots soaking in a liquid. - Whole kernel corn. - Noodles. - Mashed. (Temperature 185 degrees F. Cook #1 said the potatoes were not Duchess potatoes as identified on the planned menu). - Beef gravy. On 6/13/19 at 11:50 A.M., Cook #1 plated the food, as called out by the FSD. Cook #1 removed the top portion of a Salisbury steak patty from the top of the stack During interview on 6/13/19 at 2:20 P.M., Resident #11 said the quality of the food has changed drastically over the past few months. Resident #11 said he/she cannot eat the mashed potatoes here, and all he/she ate at lunch was the sliced carrots. 3. On 6/17/19 at 11:15 A.M., the surveyor arrived to the kitchen to observe the tray line, as part of conducting a test tray observation. Review of the Lunch-Regular meal to be served 6/17/19 consisted of the following: open faced turkey sandwich; lemon pepper fish; whole kernel corn; seasoned zucchini; mashed potatoes; parslied rice; and deluxe fruit salad. At 11:32 A.M., the surveyor observed as DA #4 opened a cabinet under the counter, and removed metal plate pallets, using pot holders. DA #4 placed two tall stacks on the top shelf of a plastic cart. DA #4 obtained hollow, plastic holders, and placed a metal plate pallet into each of these holders. She stacked them on the second shelf of the cart, awaiting Cook #1. At 11:37 A.M., Cook #1 obtained a large, rectangular baking pan, placed it on the left side of the stove, covering the left front and back burners, filled water pitchers from the faucet and poured the water into the large baking pan with approximately 1 of water. Now, DA #2 placed a large chafing dish, containing mashed potatoes, and covered with plastic wrap, into the steamer oven. At 11:38 A.M., Cook #1 told DA #2 the vegetables and turkey were ready to be put out. At 11:40 A.M., Cook #1 obtained a temperature of the lemon fish portions, and said the reading on the digital thermometer was 140 degrees Fahrenheit (F). However, the surveyor observed the digital reading as being 134.5. Cook #1 stated he would put the fish into the steamer oven to bring the temperature up (the chaffer containing the fish portions had been stored in the warmer cabinet, underneath the counter). At 11:44 A.M., Cook #1 removed a narrow chafer pan containing turkey slices from the steamer oven, and placed it into the tap water bath (not heated yet). The chafing pan with chopped zucchini was then placed into the water bath, and left uncovered. The window was open and a cool breeze blew in and onto the food. Cook #1 turned the knobs on high, for the front and back burners under the pan of tap water, which already held turkey slices and zucchini (by placing the pans of food in water, which had not been previously heated, could decrease the temperature of the food, which would later be served to residents). The remaining foods, placed in various sized chafer pans, were set into the water bath (corn, gravy, mashed potatoes, ground/pureed turkey, pureed corn). At 11:47 A.M., Cook #1 removed the fish from the steamer oven (now temped at 180 degrees F), he had placed earlier to reheat it, and placed it into the water bath. The water bath pan now contained 8 chaffing pans of various sizes. Not all pans fit, and some were tilted, such as the pureed corn and zucchini, tilting toward the open window, where the cool breeze entered, and food remained uncovered. At 11:49 A.M., DA #4 said she needed pureed zucchini. Cook #1 had not prepared this ahead of time, and asked DA #2 to prepare two servings. DA #2 took two small bowls filled with chopped zucchini and set them on the counter while he assembled the [NAME]o coupe/blender apparatus. DA #2 placed zucchini from one of the bowls into the blender, pureed it, then asked Cook #1 if he should put it on a plate. Cook #1 said yes. The second bowl of zucchini was then pureed and placed on a plate. Pureeing the zucchini, which had been in the top of the chafer, uncovered, with the cool breeze blowing on it, then placed into small bowls, left open on the counter, then the actual puree process, would certainly bring down the temperature of the zucchini served to those two residents on the LTC unit. The surveyor observed a large metal, open shelving unit. One of the shelves had a large bucket containing glasses of milk, one container held glasses of orange juice, and another yogurt cups. All glasses, yogurt cups were soaking in water, with scattered pieces of ice chips inside each bucket. At 12:14 P.M., Food Truck #1 left the kitchen. The test tray was not prepared, or placed on this truck as instructed by the surveyor. At 12:16 P.M., DA #4 prepared the test tray. DA #4 said that Food Truck #1 could only hold 20 trays, so it would not fit on the truck. DA #2 walked the test tray up behind the first food truck. At 12:17 P.M., Cook #1 started plating food for Food Truck #2 (a thick, plastic food truck). DA #4 asked for regular fish plate, for an unidentified resident. Cook #1 turned, removed a chafer pan from the warming cabinet, underneath the counter, and placed one fish portion on the plate, along with other foods. Cook #1 left the pan of fish on the counter. At 12:21 P.M., Cook #1 plated a fish portion from the pan that was on the counter. This pan remained on the counter. At 12:24 P.M., the last tray was prepared, and placed on Food Truck #2. The test tray was then prepared. At 12:25 P.M., the surveyor followed behind Food Truck #2, transported by DA #6 to the second floor unit. At 12:27 P.M., the first resident's tray was served to an unidentified resident in the second floor DR #2. At 12:34 P.M., the last tray was served, and the test tray was obtained for testing by the surveyor with the Regional Food Service Director (FSD) standing by to witness. The FSD arrived to the unit, and said she would take over to observe as the surveyor obtained food temperatures and palatability, of the food/beverages, as follows: - Turkey slice: 133.7 degrees F. (gravy on it, was flavorful, but tepid). - Pureed turkey: 111.7 degrees F. (gravy on it, flavorful, but cool) - Ground turkey: 122.5 degrees F. (gravy on it, flavorful, but tepid) - Lemon Pepper fish: 135.6 (bland, no lemon or pepper flavor, dry and tepid) - Whole corn: 121.4 degrees F (not seasoned, tepid) - Pureed corn: 111 degrees F. (cool to taste, gummy, not palatable) - Seasoned zucchini: 119.6 degrees F (bland, not seasoned, tasteless, pale color and cool) - Mashed potatoes: 134.1 degrees F. (instant mashed, soupy, gritty, tepid, not palatable). The FSD asked if she could taste the potatoes, then proceeded to do so. The FSD said she agreed, the potatoes were not hot, and did not comment on the taste. - Milk: 54.3 degrees F. (not cold or palatable) - Coffee: 145: (tasted very warm). There was no parslied rice, pureed zucchini, pureed fish to taste, despite the surveyor requested all foods be served on the test tray that were served to residents. During discussion with the FSD, directly after the test tray was completed, the FSD stated she has made every effort to ensure hot, palatable food had been served to the residents, and still has on-going concerns with cold food, food not being prepared, as instructed, repetitive menus, foods of same color, not attractively presented. The FSD said there was nothing else the FSD/staff could do. 5. Further review of the Chef's Daily Log sheets (on 6/17/19 at 2:30 P.M., the following was identified: 6/13/19: - Temperatures were not obtained for the walk-in freezer/cooler, milk cooler and reach-in cooler for the morning or afternoon timeframes, as directed/required. -Meal Temperatures and Tasting Panel section identified none of the foods served had been tasted by the Chef for all three meals, as directed. The lunch and dinner meals did not list milk/juice/coffee as being served, and there was no temperature for any of these beverages recorded. (During observation on 6/13/19 at 11:42 A.M., the surveyor did not observe Cook #1 taste any foods prepared, prior to serving, nor were there temps taken of any beverages served, such as milk, juice, and coffee). 6/14/19: -Temperature of the milk cooler and reach-in cooler had not been recorded as being done for both the morning and afternoon, as directed. -The Meal Temperatures and Tasting Panel section identified a Taste Panel Evaluation, whereby, each food item would be rated with either an A =excellent; B = acceptable; C = recipe review needed, or D=rejected, do not serve product. None of the three meals provided documented an A, B, C or D value, as directed. There was a check mark placed next to each food item listed. The lunch and dinner meals did not list milk/juice/coffee as being served, and there was no temperature for any of these beverages recorded. 6/15/19: -Temperatures were not obtained for the walk-in freezer/cooler, milk cooler and reach-in cooler for the morning or afternoon timeframes, as directed/required. -Meal Temperatures and Tasting Panel section identified none of the foods served for breakfast and lunch meals had been tasted by the Chef, as directed. The lunch and dinner meals did not list milk/juice/coffee as being served, and there was no temperature for any of these beverages recorded. The dinner meal documented check marks after each food item, and did not indicate an A, B, C or D value, as directed. The surveyor had not been provided the Chef's Daily Log sheets for 6/16 and 6/17/19. During interview on 6/17/19 at 3:15 P.M., during Quality Assessment review, the Administrator said that the facility identified issues with the Dietary Services, reviewed it at monthly and at food committee meetings, as resident's complained. The Administrator said the company had been told on many occasions to use portable steam tables. The largest one was stored inside the Main Dining Room on the basement level (also observed by the surveyor upon the initial tour of the Main Dining Room, and Kitchen). The Administrator said despite instructing the dietary staff to use the steam tables, they just refused. The Administrator said there are challenges with the size and dynamics of the Kitchen. Please refer to F908.

Based on observation, interview and record review, the facility staff failed to ensure infection control practices were maintained to help prevent the development and transmission of communicable diseases and infections during the administration of eye ointment for 1 resident (#12) in a total sample of 13 residents. Findings include: Review of the facility procedure for Medication Administration Eye Ointments and Gels dated 7/2007, indicated the following: -perform hand hygiene -remove the cap from the medication tube, taking care to avoid touching the tip of the tube. Place the cap on a clean, dry surface (such as a tissue or gauze) -pull the lower lid down and away from the eyeball to form a pocket -squeeze the tube and apply the prescribed amount of ointment or gel from the inner surface (canthus) of the lower eyelid to the outer (canthus) surface. Do not touch the tip of the medication tube to the eye or eyelid During the medication pass observation on 6/13/19 at 8:09 A.M., Nurse # 1 was observed to administer multiple medications to Resident #12 including Altalube eye ointment (eye lubricant). Nurse #1 was observed to do the following: -after administering a nasal spray medication, with ungloved hands, to Resident #12, Nurse # 1 then donned gloves without washing her hands -removed the resident's eyeglasses, uncapped the eye ointment tube and placed the cap in her right gloved hand and closing her hand around the cap -using a tissue, held the bottom lid on the right eye down and applied approximately ¼ inch ribbon of ointment to the inside of the lower eyelid, touching the eyelid with the tube tip when applying the ointment. She then proceeded to the left eye and held the bottom left eyelid down with a tissue and applied approximately ¼ inch ribbon of ointment to the inside of the lower eyelid, touching the eyelid with the tube tip -recapped the tube and replaced it into the Altalube ointment box and placed it into the medication cart During an interview with Nurse #1 on 6/13/19 at 9:21 A.M., she said that she was aware that she touched both eyelids with the tube tip when administering the Altalube eye ointment to the resident. She said that the eye ointment is sterile and that she had contaminated it when the tube tip touched the resident's eyelids.

Based on record review and interview, the facility staff failed to determine a resident's ability to self-administer medications for 2 Residents (#25 and #34), out of a total sample of 13 residents. Findings include: Review of the facility policy entitled: Medications Self Administration, dated as revised 5/22/19, indicated that residents may administer their own medications, if requested, once the interdisciplinary team determines that this practice is safe. The resident must meet the following criteria: -must be able to read the administration label on all medications -must be able to demonstrate an ability to dispense the medications from the receptacle -must pass the Self Administration Medication test -must request permission to self-administer medications -once the request is obtained, the above assessment must be completed with results documented in the medical record. This assessment is updated at least 90 days at care plan -if the results indicate the person is capable of self-administration, the physician must be notified to obtain an order for [REDACTED].>1. During the medication observation on 6/13/19 at 8:37 A.M., Nurse #1 was observed to prepare and administer multiple medications to Resident #34. Upon reconciliation with the observed medications administered and the physician orders, it was noted that the following 2 physician ordered medications that were scheduled had not been administered: -[MEDICATION NAME] (medication used to prevent minor skin infections) 500 unit/Gram ophthalmic - apply ½ inch to left eye 3 times daily (indefinitely) scheduled at 8:00 A.M., 12:00 P.M. and 8:00 P.M. -[MEDICATION NAME] Propionate (used to prevent asthma attacks) 50 micrograms (mcg) spray - 1 spray in each nostril daily scheduled at 8:00 A.M. During an interview and review of the Medication Administration Record [REDACTED].M., she said she does not administer the resident's nasal spray and eye ointment. She said the resident keeps the nasal spray and eye ointment at his/her bedside and administers them his/herself. Record review did not indicate that the resident had been assessed to determine the ability to safely self-administer the nasal spray and eye ointment medications. Additionally, there are no physician orders for the resident to self-administer the nasal spray and eye ointment and there are no orders to indicate that the resident may keep the medications at the bedside. During an interview with Nurse #2 on 6/13/19 at 11:42 A.M., she said that she had reviewed the resident's record and there was no assessment completed for the resident for self-administration of medications. She said that there were no physician orders for the resident to self-administer the nasal spray and eye ointment and keep the medications at his/her bedside. She further said the assessment should have been completed and the physician's orders should have been in place for self-administering and keeping the medications at the bedside, but were not. 2. During interview on 6/13/19 at 1:40 P.M. with Resident #25, the surveyor observed a bottle of saline nasal spray and a container of artificial tears on the resident's bed side table. Resident #25 said he/she uses the nasal spray when he/she needs it. The resident said he/she has [MEDICATION NAME] degeneration, is legally blind, and uses the machine to read (magnifying apparatus to enlarge print on books, letters, etc.) and uses the eye drops to relieve eye discomfort / irritation. Record review identified there was no Self-administration of medication assessment completed, nor was there an order for [REDACTED]. Further review of the physician's and interim orders, from 3/2019 - 6/2019, indicated no orders for the artificial tears, eye drops, frequency. The physician's orders did indicate the nasal spray was to be instilled into each nostril three times a day. Review of the corresponding 6/2019 MAR indicated [REDACTED]. During interview on 6/17/19 at 9:27 A.M., Nurse #1, identified as being the Charge Nurse, said there was no self-administration of drug assessment completed for Resident #25, and there was no order for the eye drops, as required.

Based on observation, policy review and interview, the facility kitchen staff failed to ensure sanitary conditions when preparing/serving food for residents. Findings include: Review of the Dietary Services (dated 9/2017) policy indicated the following: - All staff members will have hair confined in a hair net or cap, and facial hair properly restrained. - All staff members will exhibit personal hygiene. During the initial kitchen observation on 6/13/19 at 8:30 A.M., Cook #1 and Dietary Aide (DA) #8 were observed with facial hair, and were not wearing facial hair restraints. The surveyor observed Cook #1, and dietary staff during the tray line for the lunch meal on 6/13/19. At 11:40 A.M. Cook #1 did not have a facial hair restraint on as he plated each resident's food. At 12:10 P.M., the surveyor observed Cook #1 walk to the sink, pick up a large, plastic pitcher, turn the faucet on, fill the pitcher with water, and pour this into the large rectangular pan. Cook #1 removed gloves, walked away from food area, returned, donned gloves, without washing his hands. The surveyor observed as Cook #1 prepared a small portion regular meal for an unidentified resident. Cook #1 picked up a butcher knife, contaminating the gloved hands, placed a Salisbury steak patty on the plate, cut it in half, placed a small portion of sliced carrots in the plate, then used a now contaminated gloved finger to tap the carrots into a mound on the plate. During interview on 6/13/19 at 12:17 P.M., the surveyor reviewed what had been observed with both Cook #1 and the Food Service Director (FSD), such as breaches in hand hygiene practices, and using contaminated gloves, touching food and not wearing facial hair restraints. Cook #1 said he knows better, and will make sure he washes his hands, before applying gloves. On 6/17/19 at 11:15 A.M., the surveyor arrived to the kitchen to observe the tray line, as part of conducting a test tray observation. At 11:17 A.M., the surveyor observed as DA # 2, with facial hair, was not wearing a facial hair restraint, as he prepared mashed potatoes in a large stock pot, on a food prep counter, to ensure food was prepared under sanitary conditions.

Based on staff interview and record review the facility staff failed to notify the resident and the resident's representative in writing the reason for transfer/discharge to the hospital as required for 1 Resident (#30) in a total sample of 12. Findings include: Record review for Resident #30 indicated he/she was sent to the hospital via 911 during 12/2017. No transfer/discharge notice was found or provided to the surveyor by facility staff. During an interview on 04/06/18 at 9:36 A.M., the Director of Nurses said that the transfer/discharge notice was not provided in writing to the resident or the resident's representative.

Based on interview, observation and record review, the Facility failed to ensure for one of one sampled resident (Resident #1) that the plan of care to prevent falls and the Instruction Manual for the rolling walker, indicating that no one should be pushed while seated on the rolling walker, were followed. On 10-25-10 Resident #1 fell and fractured a finger when being pushed by CNA #3 while seated on the platform of the rolling walker Findings included: The clinical record was reviewed and indicated that Resident #1's orientation and recall skills were intact and Resident #1 required limited staff member assistance when moving about the unit. The care plan concern initiated during July, 2010 indicated that Resident #1 required assistance with activities of daily living and interventions included assistance with transfers between surfaces and use of a wheelchair for long distances. The care plan concern initiated during July, 2010 indicated that Resident #1 was at risk for falls and interventions included the independent use of a rolling walker and staff propulsion of Resident #1 in a wheelchair for transport to meals and activities off the unit. The Instruction Manual for the rolling walker was reviewed and indicated that no one should be pushed while seated on the rolling walker. The Facility Internal Investigation Repor,t dated 10-25-10, indicated that Resident #1 fell when being pushed by CNA #3 while seated on the platform of the rolling walker. The Internal Investigation Report indicated that Resident #1 sustained a non-displaced fracture of the third digit of the middle phalanx of the right hand. Resident #1 was interviewed on 11-1-10 at 5:00 PM. Resident #1 said that Resident #1 fell while being brought from the whirlpool room back to Resident #1's bedroom after a whirlpool. Resident #1 said that Resident #1 was seated on the platform of Resident #1's rolling walker facing CNA #3 who was pushing the rolling walker in the hallway toward Resident #1's room. Resident #1 said that the wheels of the rolling walker became caught on the carpet and the rolling walker tipped over backward. Resident #1 said that Resident #1 and CNA #3 fell to the floor and Resident #1 injured Resident #1's hand in the fall. Resident #1 said that a finger was fractured. Resident #1 said that staff members normally transported Resident #1 to and from the whirlpool room by having Resident #1 sit on the platform of the rolling walker. The Surveyor inspected the rolling walker in Resident #1's room and Resident #1 said the rolling walker was the same walker involved in the alleged incident. The nurse's noted dated 10-4-10 indicated that the CNA #3 told Nurse #2 that the CNA #3 was pushing Resident #1 from the whirlpool room to Resident #1's bedroom while Resident #1 was seated on the rolling walker. The nurse's note indicated that CNA #3 told Nurse #2 that CNA #3 lost CNA #3's balance and the rolling walker tipped over. Nurse #1 was interviewed on 12-2-10 at 10:30 AM. Nurse #2 was interviewed on 12-2-10 at 10:45 AM. CNA #2 was interviewed on 12-2-10 at 11:00 AM. Nurse #2 and CNA #2 said that they worked at the Facility routinely during 3:00 PM to 11:00 PM shift and staff members routinely assisted Resident #1 to and from the whirlpool room by having Resident #1 sit on the platform of the rolling walker. Nurse #1 said that although Nurse #1 observed staff members occasionally transport Resident #1 while Resident #1 was seated on the rolling walker, Nurse #1 did not think staff members transported Resident #1 in that manner routinely.