Every finding on record at The Knolls

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure proper storage of food in accordance with professional standards for food safety. Specifically, 1) perishable foods were not labeled and dated, 2) foods were not discarded by use by date, and 3) dry goods were not stored in closed containers. .A facility policy and procedure titled Labeling and Dating, dated [DATE] and last revised on [DATE], included but was not limited to: All food items must be labeled with either a manufacturers label or handwritten label. Twice a day the dining services manager on duty will check all perishables for proper covering, labeling, and dating .It is also the responsibility of other production staff and employees to discard outdated foods and beverages as assigned or noted by management. The findings are: Observations and interviews conducted during the initial tour of the kitchen on [DATE] at 10:04 AM revealed: 1) The following unlabeled, undated, and expired dairy foods were stored in the walk-in produce refrigerator: An opened, 2.32-pound package of muenster cheese labeled with a prep date of [DATE], a use by date of [DATE], and was held 10 days past the use by the date. An opened 2.81-pound package of yellow american cheese labeled with a prep date [DATE], use by date [DATE], and was held 10 days past the use by date. An opened 1.9-pound package of blue cheese labeled with a prep date ,d+[DATE], use by date [DATE], and was held 6 days past the use by date. An opened 1.48-pound package of goat cheese labeled with a prep date [DATE], use by date [DATE], and was held 6 days past the use by date. An opened .85-pound package of shredded mild cheddar cheese labeled with a received by date [DATE] was not labeled with an opened date or use by date. An opened .9-pound package of mozzarella cheese was unlabeled/undated. Cook #1 was interviewed on [DATE] at 10:34 AM and reported that all staff are responsible to check used by dates and discard expired foods, but it is primarily the responsibility of the Managers. The Regional Manager (responsible for covering the kitchen at the time of the tour) was interviewed on [DATE] at 10:48 AM and reported: When a product is brought in by a company it should be labeled with a receiving date. If a boxed product containing multiple bags of that product is then opened, the received date, as well as the use by date found on the product box, should be carried over to each individual bag. If an item is stored in the freezer and is later pulled to thaw in the refrigerator, it should be labeled with a pull date and a use by date. If a product is opened it should be labeled with a prep date and a use by date. At that time, the Regional Manager stated that h/she would discard the above items. 2) The following unlabeled and undated frozen were stored in the walk-in freezer: 4.6-pounds of cod wrapped in in plastic wrap dated [DATE], no received date or use by date. 2.33-pounds of breaded cod stored in a clear plastic bag dated [DATE], no received date or use by date. 1.18-pounds of frozen breaded fish stored in a blue bag, unlabeled and undated. 3. The following unlabeled and undated raw meat and poultry items were stored in a walk-in refrigerator: A defrosted to touch, 10-pound package of raw ground beef labeled with a received date of [DATE], no pull date or use by date 9.7-pounds defrosted to touch, raw Chicken thighs stored in a ,d+[DATE] pan, volume exceeded top of pan, wrapped in plastic wrap, labeled frozen [DATE], no pull date or use by date 2 defrosted to touch, raw pork loin, approximately 6.5 pound each, labeled with received date [DATE], no pull date or use by date. Cook #2 was interviewed on [DATE] at 10:38AM at that time and reported that she had pulled the ground beef, chicken thighs, and pork loin from the freezer last night, she usually would label these with a pull date , but she did not have any labels. Cook #2 did not produce documentation (i.e. a pull log) to support her statement. The Regional Culinary Manager was interviewed on [DATE] at 10:38AM and reported the fish, ground beef, chicken thighs, and pork loin would be discarded. #4. Observation of dry food storage on [DATE] at 10:43 AM in Dining Room Food Service/Pantry area revealed: The following food items were not stored in closed containers : single serving cold cereal, individual portions of saltines, graham crackers, cookies, breakfast syrup, grape jelly, and individual sugar packets. The Vice President of Operations Food Service was interviewed on [DATE] at 10:43AM and reported that the dry foods would be stored in closed containers. An interview conducted with the Food Service Director on [DATE] 01:24 PM revealed his/her expectation fo dating and labeling were: Everything that is consumable should be dated on received date. If multiple items come in one box, the received date can be on the box. Then, if the cooks take out part of the item and some items remain, then the received date should be labeled on the remaining items. Items that are pulled from the freezer should be labeled with a pull date, the guidance for use by date varies, and there is a listing on the freezer and walk in refrigerators which will indicate how long the items can be held for under refrigeration. When asked if there should be any other labeling besides the pull by date for the frozen foods, FSD reported there might be a use by date. For products such as cheese, if the cheese stays in the box the received date will be on the box, if individual bags of cheese are used staff must label all bags with the same received date as on the box. If the cheese is opened it is labeled with an opened date, the expiration date must be checked on the refrigeration guidance sheet and should cheese labeled with a discard date. For frozen items that are partially used, i.e. an opened bag of frozen breaded fish fillets, these should be labeled with received by date, an opened date, and a discard date. 415.14(h)

Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that comprehensive person-centered care plans with measurable goals and interventions were reviewed and revised for 1 of 5 Residents (Resident #63) reviewed for unnecessary medications. Specifically, (1) A Pharmacy Drug Review was conducted for Resident #63 and revealed a drug-drug interaction of concurrent use of Aspirin and [MEDICATION(S)] medication may increase the risk of bleeding and to monitor the resident; (2) There was no documented evidence the residents' care plans were reviewed and revised to reflect the drug-drug interactions as identified by the Pharmacist; (3) There was no evidence these changes were communicated among the nursing staff for ongoing monitoring; and (4) There was no documented evidence that Resident #63 was monitored for bleeding, side effects/adverse effects of the medications. The findings are: 1. Resident # 63 is a [AGE] year-old who was admit to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 6/22/2021 5-Day Minimum Data Set (MDS; a resident assessment and screening tool), the resident had moderate impaired cognition, and required extensive staff assistance with activities of daily living (ADLs). Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan (CP) titled At Risk for Bleeding was initiated on 6/15/2021. The CP listed the medication ASA 81mg chewable tablet oral daily. Goals included signs and symptoms of minor bleeding would be detected early. Interventions included, but not limited to monitor for any signs and symptoms of bleeding, increase bruising, and notify the physician for any increase bleeding or abnormal labs. A [CONDITION(S)] Drug Use Care initiated on 6/15/2021 listed medication [MEDICATION(S)] 40mg capsule oral daily and [MEDICATION(S)] 5mg oral daily. Goals included the resident would be free of complications associated with the use of [CONDITION(S)] medication. Interventions included to assess and evaluate for effectiveness and/ or adverse reaction on an ongoing basis, and to monitor for signs and symptoms of complication and report to the physician. A Pharmacy Drug Review was conducted on 6/24/2021. The Pharmacist documented concurrent use of the Aspirin and [MEDICATION(S)] medication may increase the risk for bleeding and to monitor the resident. Further review of the above At Risk for Bleeding Care Plan, as well as other Care Plans revealed they were not updated with the Pharmacist drug-drug interaction information. There was no documented evidence that the resident was monitored for bleeding as recommended by the Pharmacist or monitored for the ongoing use of the medication's effects/ side effects, or adverse reactions. Nurses Progress Notes 6/14/2021 to 7/6/2021 revealed no documented evidence of medication effects/adverse reaction, bleeding, or documentation of the pharmacist recommendation of the drug-drug interaction between the medications as described above. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence that the above pharmacy drug-drug interaction recommendation to monitor the resident were transcribed to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 was asked if the information was documented on a treatment record to which h/she replied the resident had no treatment record. In an interview with the Director of Nursing (DON) on 7/1/2021 at 11: 50AM, h/she stated it was the nursing staff responsibility to make sure the pharmacist recommendations, as indicated above, were documented on the resident's care plan for the staff to follow up. In an interview with RN #1 on 7/1/2021 at 12:05PM regarding the above pharmacy review, h/she stated that pharmacy medication reviews are done monthly. If the information was for nursing, such as monitoring for bleeding, the information would be documented on the resident's care plan for the nurses to monitor. RN #1stated that the pharmacy drug-drug interaction recommendations should have been documented on the resident's care plan. RN #1 was asked who was responsible to initiate and update residents' care plans. H/She stated that the nurses, including the Director of Nursing, were responsible for initiating and updating residents' care plans. During a follow up interview with RN #1 on 7/06/21 at 3:48 PM, h/she stated that there was no documentation that the staff were monitoring the resident for bleeding. It should have been done. The nurses were responsible for monitoring and documenting in the Progress Notes. 415.11 (c) (2) (i-iii)

Based on interview and observation conducted during a recertification survey, it could not be ensured that the facility provided care and treatment in accordance with professional standards of practice. Specifically, the facility did not ensure that a change in skin condition was reported and treated timely for 1 of 1 resident (Resident #7) reviewed for skin conditions (non-pressure). The finding is: The facility policy and procedure titled Skin Care/Personal Grooming, dated 1/15/2002 and revised 12/2014 documented: Certified Nursimg Assistant (CNA) responsibility during AM bed bath, shower, or tub bath, inspects resident's skin for any redness, dryness, cracking, etc. Report any finding to Nurse. Licensed Nurse responsibility: Checks and cleans skin as necessary .Report any changes to the Nurse Manager/Supervisor, MD/Nurse Practitioner. Resident #7 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS: an assessment tool) dated 8/20/2020 documented moderately impaired cognition for decision making, one unhealed stage 3 Pressure ulcer, Skin and ulcer treatments included: pressure reducing device for chair and bed, turn and positioning program, Nutrition or hydration intervention, pressure ulcer/injury care, and application of ointments/medications other than to feet. A subsequent Quarterly MDS dated [DATE] documented severely impaired cognition for decision making, and skin and ulcer treatments: pressure reducing device for chair and bed, turn and position program, nutrition or hydration intervention, pressure ulcer/injury care, application of ointments/medications other than to feet. The Resident's Comprehensive Care Plan (CCP) documented risk for skin breakdown related to Braden score ( a skin risk assessment) of 13, limited mobility, and history of previous skin breakdown. Interventions included: monitor for any kind of skin breakdown and report to MD (medical doctor) / NP (nurse pracitioner). Surveyor observation on 6/29/21 at 2:15 PM revealed a small round area, visually estimated to be .5 inch in diameter with a yellowish center, on the resident's left upper forearm. The 6/25/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Following surveyor inquiry, new orders were noted dated 7/2/2021 [MEDICATION(S)] 2% topical ointment apply to topical route 2x/day to lesion and left arm, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Registered Nurse #1 on 7/2/21 at about 3:50 PM revealed: RN #1 was not aware of a skin issue on the resident's left upper forearm. At that time, RN and Surveyor went to speak with Resident #7 and RN #1 observed the resident's left forearm with Surveyor present. Surveyor again observed a small round area about .5 inch in diameter with a yellowish center on the resident's left upper forearm, however the area surrounding the yellowish center was now observed to be slightly reddened. RN #1 reported that h/she had not observed the skin change previously, had not been notified of it, and further revealed h/she would be calling the Resident's doctor. Certified Nurse Aide (CNA #1) was interviewed on 7/06/21 at 9:28 AM and reported: H/She was assigned to Resident #7 last month 6/2021, h/she noticed a change to resident's forearm just above the wrist (CNA #1 identified area by pointing to her own left wrist), could not recall which side, h/she observed a black spot on Wednesday 6/30, h/she tried to report it to the RN #1, and RN #1 was busy so h/she did not get to tell him/her, and did not recall providing care to resident after that. CNA #1 further stated that h/she checked the resident's skin daily in the morning and if h/she sees something, h/she calls the nurse right away to look at. CNA #2 was interviewed on 7/06/21 10:13 AM reported: H/She is assigned to Resident #7 for this month 7/2021 and does a skin check every morning when washing the resident and during showers. Further reported that on 7/1/21 the resident had something on her left arm, like a little pimple, could recall what color, (CNA #2 identified site of pimple by pointing to her own left arm above watch strap), h/she did not report to the nurse and h/she should have, but h/she was just coming over to the assignment and assumed it had been reported. In a follow up interview on 7/6/2021, RN #1 reported that h/she had not been notified by CNA of any change in skin condition and it was the responsibility of the CNA to report any skin changes to the RN. 415.12

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that facility staff accurately measured a resident's fluid intake to maintain proper hydration and health. Specifically,fluid restriction related to abnormal lab values was not followed for one of one resident (Resident #64) reviewed for hydration. Facility staff members did not accurately measure the resident's fluid intake during a recent lunch observation. The findings are: Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 6/16/2021 Admission Minimum Data Set (MDS; a resident assessment and screening tool), the resident had moderate impaired cognition and required extensive staff assistance with activities of daily living (ADLs). A Medical Nutrition Therapy Care Plan initiated 6/16/2021 and updated on 6/23/2021, documented the resident was at risk for altered nutrition/hydration status. The resident was on fluid restriction of 1500ml/day. Goals included the resident would be free from signs/symptoms of dehydration, such as high blood urea [MEDICATION(S)] (BUN) and or electrolytes. Interventions included to assess intake and to monitor for signs and symptoms of dehydration. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing/Dietary Fluid Restriction Sheet, dated 6/17/2021, showed the breakdown of the resident's fluid intake between the nursing and dietary staff as follow: -Nursing 7A-3PM shift =120ml, 3PM-11PM =120ml, 11PM-7AM = 60ml, (Total 300ml) -Dietary Breakfast: 4 oz milk (120ml), 8 oz coffee (240ml), 4 oz juice (120ml) = 480ml total fluid., Lunch: 4 oz tea (120ml), 2 oz milk (60ml) = 180ml total., Dinner: 4 oz tea (120ml), 2 oz milk (60ml), 4 oz soup (120ml) = 300ml total., 2 PM snack: 4 oz juice (120ml), 8PM snack: 4 oz juice (120ml), (Total 1,200ml), (Total fluid in 24 hours = 1500ml). Physicians' Progress Notes dated 6/18/2021 revealed the resident had a low sodium level of 128 with plans to restrict fluids. Nutrition Progress Note dated 6/23/2021 documented the resident's labs of 6/10/2021 showed abnormal sodium level of 128. The resident was placed on 1500ml fluid restriction as follow: -Nursing , 7A-3PM shift =120ml, 3PM-11PM =120ml 11PM-7AM = 60ml, (Total 300ml) -Dietary , Breakfast = 480ml, Lunch = 180ml, Dinner = 300ml, 2 PM snack =120ml, 8PM snack = 120ml, (Total fluid in 24 hours = 1500ml). During a lunch meal observation on 6/29/21 at 1:38 PM, a dietary worker poured unmeasured milk and tea in cups that were not calibrated for Resident #64 who was on 1500ml of fluid restrictions in a 24-hour period. Similar cups to the ones the resident was served with were compared and revealed the cup that the milk was served in was engraved with 9 oz size at the bottom and contained approximately 120ml milk or more. The cup with the tea was almost full of approximately 240ml of fluid. The cup had no measurements. The resident's lunch meal ticket dated 6/29/2021 stated fluid restriction with special instructions to give half a cup of tea and 2 oz of milk. In an attempt to correct the excessive fluid that was served to the resident, Registered Nurse (RN #1) poured off some of the fluids of both cups without using a measuring device for accuracy. During an interview with Registered Nurse (RN #) on 6/30/2021 at 1:50PM, h/she stated that the dietary department was responsible to make sure the resident's fluids were measured correctly. The fluids should have been measured by the dietary server when preparing the resident's meal trays. RN #1 said h/she was aware of the resident's fluid restrictions. H/She stated that h/she had noticed that the dietary server had poured an excessive amount of milk and tea in the cups that were not calibrated. RN #1 stated that the fluids the dietary server poured into the cups were way too much. H/She stated that was why h/she had to pour off some of the fluids, based on her judgement of what the amount should have been in each cup. RN #1 was asked why h/she had poured off the fluids based on her judgement, instead of getting calibrated cups to measure the fluids accurately. H/She stated that h/she did not want to leave the dining area. An interview was conducted with the Dietary Aide (DA), on 7/1/2021 at 1:45PM, related to the inaccurate amount of fluid that h/she had served the resident on 6/29/2021. H/She stated that h/she was aware the resident was on fluid restriction, but not the overall total. The resident should have received 4oz of coffee or tea, and 2 or 4 oz of milk. H/She stated that h/she thought h/she had poured the correct amount of fluid on that day, even though h/she did not use a measuring cup. The DA stated that h/she realized that h/she had poured an excess amount of fluid in the resident's cups after h/she was counseled by her manager. H/She stated h/she did not measure the fluids because h/she did not have a measuring cup. The DA stated that h/she should have used the measuring cups to serve the resident's fluids. The DA stated that h/she did not inform her manager that the measuring cups were not available. H/She stated there was documentation of the fluid breakdown between nursing and dietary, but h/she did not look at it on that day. The DA stated that h/she should have looked at it daily during serving of meals. H/She stated that the dietary aides who serve the meals are responsible to make sure the fluids are measured correctly. H/She stated that on that day, the resident got an excess amount of approximately 2 oz over the required amount. The DA said the fluid restriction information was documented on the resident's meal ticket. In an interview with the Registered Dietician (RD) on 7/2/2021 at 12:19PM, h/she stated that the resident was on ml fluid restrictions related to low sodium levels. The resident's fluid breakdown included 4oz of juice at 2PM and 4oz at 8PM. H/She stated the staff are supposed to be measuring the resident's fluids. Measuring cups are available. The RD stated that h/she was informed that the dietary worker gave the resident excessive fluid. H/She stated that dietary and nursing are responsible to make sure the resident's fluids are measured accurately. The server was in-serviced about the incident. An interview with the assigned CNA #3 on 7/2/2021 at 12:38PM revealed the resident was on fluid restriction. H/She stated that the food servers are responsible for measuring the fluids before putting it on the tray; the nursing staff is responsible for double checking to make sure the fluids are accurate. The resident's fluid restriction is documented on the meal tickets. The tickets tell how much fluid is required with each meal. The resident's fluids are broken down between nursing and dietary. 415.12 (i) (1)

Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that the irregularities identified by the Pharmacist were communicated to the resident's primary medical doctor and acted upon. Specifically, monitoring of the Resident's blood levels of [MEDICATION(S)] did not occur in accordance with the physician's orders. This was evident for 1 (Resident #7) out of 5 residents reviewed for Unnecessary Medications. The finding is: An undated facility policy and procedure titled Drug Regimen Review revealed: The consultant pharmacist reviews the physician's orders, lab test result, nurse's notes, physician's notes, and resident's background in performing drug regimen reviews of each resident on a monthly basis; identifies a possible irregularity during the resident's monthly drug regimen review; reports irregularity on a two-part drug regimen review form; completes the upper portion of the form supplying the following information: Date drug regimen review written, Resident's name and room number, prescribing physician's name; provides a brief statement as to recommendation, signs and dates the form, retains a copy in binder, and original copy is placed in MD communication book on unit. The Attending Physician/Nurse Practitioner (NP) documents response to the pharmacist's comments in the area provided. Resident #7 was admitted on [DATE] with diagnoses including [CONDITION(S)], Major Depressive Disorder, Alzheimer's disease A significant change Minimum Data Set (MDS: an assessment tool) dated 8/20/2020 documented moderately impaired cognition for decision making, and antidepressant medication was administered 7/7 previous days. A subsequent Quarterly MDS dated [DATE] documented severely impaired cognition for decision making, and antidepressant medication was administered 7/7 previous days. The Comprehensive Care Plan (CCP) titled Actual / Potential Drug Related Complications secondary to use of [CONDITION(S)] drug as demonstrated by : Medication used: [MEDICATION(S)] [MEDICATION(S)] 300 mg 3x/week Monday/Wednesday/Friday, [MEDICATION(S)] [MEDICATION(S)] 300 mg once daily, [MEDICATION(S)] 15 mg 7.5 mg once daily. Updated 6/17/21: [MEDICATION(S)] 25 mg daily at HS. Goal: Resident will be free from complications associated with the use of [CONDITION(S)] medication daily x 90 days. Interventions included: monitor lab results per MD order. Care Plan progress notes dated 10/30/20, 11/14/20, 2/20/21, 5/20/21, and 6/17/21 did not address [MEDICATION(S)] levels. Observations of Resident #7 revealed on 6/29/21 at 01:53 PM Resident #7 was sitting in dining room waiting for lunch, became tearful, face sad, making soft distressed sounds. Resident self-calmed after a couple of minutes, then again became tearful with sad facial expression, this time with more audible distressed sounds. Staff responded by asking resident what was wrong, no explanation offered by resident, and staff explained to Resident that she was going to get her lunch for her and resident calmed. Physician's order dated 6/25/21 included: [MEDICATION(S)] level every 3 months, [MEDICATION(S)] [MEDICATION(S)] 300 mg , 1 capsule by oral route 3x/week M/W/F at 10:00 AM dx [CONDITION(S)] d/o, current episode depressed, mild. [MEDICATION(S)] [MEDICATION(S)] 300 mg , 1 capsule daily at 8 pm dx [CONDITION(S)] d/o, current episode depressed, mild. Review of the record revealed: Lab reports for [MEDICATION(S)] levels were completed on 8/11/2020, 1/21/2021, and 5/27/2021. A time frame of 5 months elapsed between [MEDICATION(S)] level of 8/11/2020 and 1/21/2021. A time frame of 4 months elapsed between [MEDICATION(S)] levels of 1/21/21 and 5/27/21. Upon Surveyor request to the Director of Nursing (DON) (Patricia) for Resident #7's Medication Regimen Review (MRR) for the past six months, DON responded by providing a copy of the Pharmacy Consulting Services Quality Assurance Performance Improvement Material report for all facility residents from 1/20/21 through 6/24/21. Resident #7 was noted by the Pharmacist in that report as follows: Critical Elements- Lab orders not on file: 11/2020 [MEDICATION(S)] level Critical Element Irregularity noted: Lab order is not on file. 4/2021 [MEDICATION(S)] Level (ordered every three months). Additionally, the DON provided a copy of the Consultant Pharmacist Medication Regimen Review Accountability Record which was specific to Resident #7, and documented the following: 1/20/21: QA findings forwarded to Director of Nursing: Check 11/2020 [MEDICATION(S)] level., 2/17/21: Medication Regimen Reviewed: [MEDICATION(S)] 1/21/21, 5/26/21: QA findings forwarded to Director of Nursing: Check 4/2021 [MEDICATION(S)] level. There was no documented evidence that: The Physician was notified of the irregularities and that [MEDICATION(S)] levels were not being checked in accordance to the Physician's orders. , Any action had been taken to address the irregularities. A telephone interview of the Medical Director/resident's primary medical doctor (PMD) on 07/02/21 at 10:10 AM revealed: in regard to MRR recommendations for the DON to check labs: if the labs were done and MD documented them, then it is not necessary to inform the MD. If the labs were not done the MD should be notified. Interview of the DON conducted on 07/06/21 at 2:30 PM revealed: for Quality Assurance (QA) issues on the MRR, the following actions are taken: For lab reports not on file: the DON gets a copy of the QA from MRR and gives it to the nurse going on shift, usually the 3-11 shift. The nurse makes sure the lab is there. If the lab is not there, nursing will ensure the lab is done. There is no documentation of this action. In a follow up interview later that afternoon, the DON revealed that no [MEDICATION(S)] level was found for 11/2020 and 4/2021. The Registered Nurse (RN #2, 3-11 shift) ) was interviewed on 7/6/2021 at 4:35 pm and reported that h/she was not aware of the missed/late [MEDICATION(S)] levels for Resident #7, and further reported that if h/she had been aware h/she would have called the lab and if the lab was delayed would call MD. The Registered Nurse (RN #1, 7 am -3 pm shift) was interviewed on 7/6/2021 at 4:45 PM and reported h/she was not aware of late/missed [MEDICATION(S)] levels for Resident #7, and further reported that if h/she was aware h/she would have called the MD. A follow up interview of the Pharmacy Consultant was conducted 7/6/2021 at 4:50 PM and revealed: no MRR irregularity was sent to MD regarding the late/missed [MEDICATION(S)] levels, and further revealed that MD received the QA form which documented the missing [MEDICATION(S)] levels. 415.18 (c)(2)

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that facility staff provided ongoing monitoring of a resident for medication effect, side effects, adverse reaction, or any associated behavioral effects of the medication. Specifically, 1of 5 residents (Resident # 63) reviewed for unnecessary medication revealed no evidence of ongoing monitoring for the use of an antipsychotic medication, [MEDICATION(S)], used to treat Anxiety Disorder. Additionally, a Pharmacy Drug Review revealed a drug-drug interaction of increased bleeding between Aspirin and [MEDICATION(S)] (anti-depressive medication). There was no evidence that the resident was monitored for bleeding as recommended by the pharmacist. The findings are: Resident # 63 is a [AGE] year-old who was admit to the facility on [DATE] with diagnoses and conditions including Depression, Anxiety Disorder, [CONDITION(S)], and Heart Failure. Physician Orders dated 6/14/2021 included medication orders for [MEDICATION(S)] 5mg tablet oral daily at 5PM for Anxiety Disorder, Aspirin 81mg chewable tablet oral daily at 10AM for Heart Failure, and [MEDICATION(S)] 40mg capsule oral daily at 10AM for Major Depressive Disorder. A Care Plan (CP) titled At Risk for Bleeding was initiated on 6/15/2021. The CP listed the medication ASA 81mg chewable tablet oral daily. Goals included signs and symptoms of minor bleeding would be detected early. Interventions included, but not limited to monitor for any signs and symptoms of bleeding, increase bruising, and notify the physician for any increase bleeding or abnormal labs. A [CONDITION(S)] Drug Use Care initiated on 6/15/2021 listed medication [MEDICATION(S)] 40mg capsule oral daily and [MEDICATION(S)] 5mg oral daily. Goals included the resident would be free of complications associated with the use of [CONDITION(S)] medication. Interventions included to assess and evaluate for effectiveness and/ or adverse reaction on an ongoing basis, and to monitor for signs and symptoms of complication and report to the physician. According to the 6/22/2021 5-Day Minimum Data Set (MDS; a resident assessment and screening tool), the resident had moderate impaired cognition, and required extensive staff assistance with activities of daily living (ADLs). A Pharmacy Drug Review was conducted on 6/24/2021. The Pharmacist documented concurrent use of the Aspirin and [MEDICATION(S)] medication may increase the risk for bleeding and to monitor the resident. Nurses Progress Notes 6/14/2021 to 7/6/2021 revealed no documented evidence of behavior monitoring, medication effects/adverse reaction, bleeding, or documentation of the pharmacist recommendation of the drug-drug interaction between the medications as described above. The Medication Administration Record (MAR) from 6/24/2021 to 7/24/2021 was viewed in the presence of Registered Nurse (RN #1) on 7/1/2021 at 12:05PM and revealed Resident #63 currently ordered for Aspirin 81mg chewable tablet daily at 10AM and [MEDICATION(S)] 40mg capsule oral daily at 10AM daily. There was no evidence that the above pharmacy drug-drug interaction and recommendation to monitor the resident were transcribed to the MAR to alert the nurses of the risk of bleeding from these medications. RN #1 was asked if the information was documented on a treatment record to which h/she replied the resident had no treatment record. In an interview with the Director of Nursing (DON) on 7/1/2021 at 11: 50AM, h/she stated that it was the nursing staff responsibility to make sure the pharmacist recommendations, as indicated above, were documented on the resident's care plan for the staff to follow up. In an interview with RN #1 on 7/1/2021 at 12:05PM regarding the above pharmacy review, h/she stated that pharmacy medication reviews are done monthly. If the information was for nursing, such as monitoring for bleeding, the information would be documented on the resident's care plan for the nurses to monitor. RN #1stated that the pharmacy drug-drug interaction recommendation should have been documented on the resident's care plan. During a follow up interview with RN #1 on 7/06/21 at 3:48 PM, h/she stated that there was no documentation that the staff were monitoring the resident for bleeding and behavior. They should have been done. The nurses were responsible for monitoring and documenting in the Progress Notes. 415.12(1)(2)(i)

Based on observation and staff interview during the Life Safety Recertification survey, the facility did not ensure all applicable state codes were met. Specifically, the facility did not install a carbon monoxide detector in accordance with section 915 of the 2015 edition of the International Fire Code, as adopted by New York State and contained in the NYS Uniform Code Supplement Section 915.3, which requires carbon monoxide detection in buildings with fuel-burning appliances. The finding is On 06/29/21 at approximately 11:10 AM, a tour of the nursing unit revealed one gas dryer located in a closet at the end of the corridor near resident room F213. Further observation at this time revealed a carbon monoxide detector was not installed in the closet where the gas dryer was located or throughout the corridor near the gas dryer. In an interview at this time, the Maintenance Director stated carbon monoxide detection will be installed in the corridor. 10 NYCRR: 415.29 (a)(2), 711.2 (a)(1); 42 CFR: 483.70 (b), 2015 IFC: Section 915, 915.1, 915.1.4, Section 1103.9

Based on record review and staff interview, the facility did not ensure that a Legionella Risk Assessment and Water Management Plan was provided in accordance with Section 483.80. Specifically, the facility did not ensure that the Legionella Program was assessed at least annually. The findings are Record review of the facility's Legionella Program revealed a document titled Water Management Plan - The Knolls 1/15/2020 Prepared by Sound Water Treatment, Inc. Revised January 2020. Additional record review at this time revealed the DOH-5222 document was also dated January 15,2020. In an interview on 06/30/21 at approximately 12:40 PM, the Maintenance Director stated that the Legionella Program should be reviewed annually. 483.80(a)(1)(2)(4)(e)(f)

Based on record review and interviews conducted during a recertification survey, the facility did not ensure that all MDS (Minimum Data Set; a resident assessment and screening tool) were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within 14 days of the final completion date, or event date in the case of Entry and Death in facility situations for 6 of 6 residents reviewed for resident assessment. Specifically, residents (R) (#1, #2, #7, #9, #13 and #15 ) did not have the MDS data submitted within 14 days of completion of the MDS assessment. The Findings Included: The following residents were reviewed for Resident Assessment: - R #1 had a Death in the Facility with an ARD (Assessment Reference Date) of 4/30/18 which was submitted on 6/27/18; - R #2 had a Discharge Assessment with an ARD of 2/1/18 which was submitted on 7/2/18; - R #7 had a Death in Facility Assessment with an ARD of 5/1/18 which was submitted on 6/28/18; - R #9 had a Quarterly Assessment with an ARD of 4/12/18 which was submitted on 6/28/18; - R #13 had a Quarterly Assessment with an ARD of 4/20/18 which was submitted on 6/28/18; - R #15 had a Discharge Assessment with an ARD of 2/20/18 which was submitted on 7/2/18. The facility MDS corporate Registered Nurse coordinator was interviewed on 7/3/18 at 10:53 AM and she said that the assessments should have been submitted within 14 days of completion. She said the above MDS Assessments were submitted late. She said she was responsible for signing off and submitting all MDS in three facilities. 415.11

Based on observation, record review, and interview conducted during a recertification survey, the facility did not ensure for 1 of 1 resident reviewed for [MEDICAL TREATMENT]/nutrition (Resident #116) that monitoring of fluid intake for this resident on fluid restriction was consistently done to prevent fluid overload. The findings are: Resident #116 was admitted to the facility on [DATE] for short term rehabilitation following a hospitalization for back pain and undergoing [MEDICAL TREATMENT] for End Stage [MEDICAL CONDITIONS]. The 5-day Minimum Data Set (MDS; a resident assessment and screening tool) dated 6/12/18 indicated the resident's weight was 179 lbs and height was 62 inches at the time of the assessment. This MDS further indicated that there was no/unknown significant weight loss or gain in the past 1-6 months, was receiving a therapeutic diet while a resident, and that the resident was receiving [MEDICAL TREATMENT] treatments, as a resident and while not a resident. The resident was interviewed on 6/21/18 at 10:20 AM and she stated she has been receiving [MEDICAL TREATMENT] treatments for the past [AGE] years. The (MONTH) (YEAR) care plan for Medical Nutrition Therapy indicated that the resident is at risk for altered nutrition/hydration as evidenced by therapeutic diet, End Stage [MEDICAL CONDITION] and Stage II pressure ulcer. Interventions included renal diet - 100 gm protein and 1000 cc/day fluid restriction. There was no indication on the care plan or in the dietary notes of how the fluid restriction should be divided and monitored, between the amount of fluids given by dietary during meals and nursing. The unit medication Licensed Practical Nurse was interviewed on 7/2/18 at 12:50 PM and she stated that the nurses record at each shift how much they provided to the resident for med pass. There was no breakdown of how much the resident may have. The Food Service Director (FSD) was interviewed on 7/2/18 at 1:00 PM regarding the breakdown for the fluid restriction for the resident. He stated that the dietitian does that. When asked if he has any documentation by the dietitian for the dietary/ meal by meal allowance for fluid, he stated there was none. The FSD further stated that he does not know what is being provided to the resident at each meal. The dietitian was not available for interview. The Certified Nurse Aide (CNA) Accountability for food and fluid intake for the month of (MONTH) (YEAR) indicated that the resident drinks between 1/2 (50%) and all (100%) the fluid that is provided to her. The amount of fluids actually consumed by the resident was not recorded. The CNA assigned to document the residents' intake during meals was interviewed on 7/2/18 at 1:15 PM and stated that the aides just write 1/4, 1/2, 3/4 or A (all) of how much of the fluid the resident drinks that is provided at meals. They do not estimate the amount the residents were drinking. The Intake/Output record filled out by the nurse (LPN) from 6/26/18 - 7/2/18 recorded how much the resident was drinking during medication pass. The Fluid Restriction Recommendations printed on the Intake/Output record indicated the following: 1000 cc: 640 from Dietary/360 from Nursing. Review of the documentation of fluid intake by nursing indicated that fluids provided by nursing ranged from 420 cc to 600 cc. A second LPN who was providing medications to the resident that day was interviewed on 7/3/18 at 9:30 AM regarding how much fluids the resident can have. This LPN provided a document that she said was prepared by the Dietitian. The document provided indicated that the resident is on a 1000 cc fluid restriction and should receive the following amount of fluids during each meal: - Breakfast - 4 oz. milk, 4 oz. beverage - Lunch - 4 oz. beverage - Dinner - 4 oz. beverage, 4 oz. soup. Total = 20 oz. or 660 cc. for dietary and 340 for nursing The regional dietitian was interviewed on 7/3/18 at 9:45 AM regarding how much fluid the resident receives at meals and she provided the following order: 6/27/18 - renal diet; 1000 cc/day fluid; 6 oz. beverage at breakfast; 4 oz. beverage at lunch; and 4 oz. beverage at dinner. Total is 14 oz. or 420 cc. The unit Licensed Practical Nurse was interviewed on 7/3/18 at 10:40 AM regarding which fluid restriction breakdown she uses and she stated the fluid restrictions sheet provided by the dietitian. In a follow up interview with the regional dietitian on 07/03/18 at 11:39 AM regarding the different fluid restriction instructions, she stated she realized they need to use just one of the breakdowns so the resident is provided with the correct amount of fluid. 415.11(c)(1)

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards in 1 of 4 emergency boxes (E-box) currently in use in the facility. Specifically, E-Box #3 contained 2 vials of medication and 3 normal saline intravenous (IV) flush syringes had past due expiration dates. The Findings Include: Medication storage review was conducted on [DATE] at 10:00 AM and the following was observed on the Fieldstone Unit. E-box #3 was inspected and showed that the normal saline IV flush syringes had past due expiration dates. Three Medifill 12 milliliter Normal Saline IV Flush Syringes with a 10 milliliter fill had an expiration date of ,[DATE] and two vials of [MEDICATION NAME] and Sulbactan (3 grams) for injection had an expiration date of ,[DATE]. The unit Registered Nurse (RN) manager was interviewed on [DATE] at 10:31 AM and stated that the night nurses are responsible for checking the emergency boxes. The RN manager stated that the boxes are supposed to be checked every night, and that if a medication is expired the nurse would fill out a paper send the paper to facility pharmacy, the pharmacy would, it will be sent for replacement. The nurse would then return the medication to the pharmacy. She said any supplies that had expired in the E-box containing IV, the nurse would send the whole box with its contents to the pharmacy and a replacement box would be brought back to the facility. The Pharmacy Consultant was interviewed on [DATE] at 10:45 AM and she said the medications and supplies which had expired should have been removed on (MONTH) 1 2108. She said the E-box containing the medications did not go back to the pharmacy. She added that the facility is responsible for checking these meds for expiration dates. 415.18(e)(,[DATE])

Based on observation, interview, and record review conducted during a recertification survey, the facility failed to have an effective system in place to ensure that foods were properly stored within safe temperature ranges, in accordance with professional standards for food service safety, to prevent potential food borne illness. Specifically, food service workers failed to report, ensure timely repair and/or implement an alternative plan to address a malfunctioning freezer when recorded temperatures were in unacceptable ranges. The freezer storage temperature was not maintained at zero degrees Fahrenheit (F), with recorded temperatures between 25 and 30 degrees F according to the facility log, for a period of fifteen days from 3/5/17 - 3/20/17. Potentially Hazardous Foods and Time and Temperature Controlled for Safety Foods (PHF/TCS) stored in the freezer were not maintained in a frozen solid state to prevent potential for food borne illnesses. Multiple meat items considered as potentially hazardous foods and other foods were held in the freezer during that time period, including uncooked brisket and cooked meat loaf dated 12/1/17 and 12/18/17, respectively. On 3/22/17, the food items were noted to be thawed and temperatures ranged from 28 to 38 degrees F. This resulted in immediate jeopardy potentially affecting all 14 residents of the facility. Additionally, sanitary conditions and required food handling practices were not observed by multiple food service workers in the kitchen and during meal service observations. The findings are: Cross References: F456 - Essential Equipment = L F490 - Administration/ Resident Well-Being = L 1. Food Storage and Temperature An initial tour of the facility kitchen was conducted on 3/22/17 between 9:20 AM - 11:00 AM. It was observed that the freezer's external thermometer gauge recorded 28 degrees Fahrenheit (F) and the internal temperature was 36 degrees. Multiple PHF/TCS foods found in the freezer, some undated, were soft to touch and were not in frozen solid states including, but not limited to: - uncooked brisket dated 12/1/16 was not frozen solid and was soft to touch; - uncooked pork butt dated 12/12/16 was not frozen solid; - a piece of meat loaf dated 12/18/16 was not frozen solid to touch; - lamb chops dated 1/1/17 was soft to touch; - an expired unopened package of pancetta, with sell-by-date of 1/11/17 was soft to touch; - uncooked duck breast dated 1/26/17 with a temperature of 32-33 degrees F; - a large cooked roast beef dated 1/30/17 was soft to touch with a temperature of 30 degrees F (the facility provided their own thermometer); - pureed eggplant dated 3/8/17 with a temperature of 30.5 degrees F; - beef tenderloin tips delivered on 3/9/17 was defrosted; - two pieces of salmon wrapped in plastic dated 3/16/17 was soft to touch and not frozen solid; the temperature of the salmon was 32.5 degrees F; - jumbo stuffed shells were not frozen solid and had a temperature of 31.7 degrees F; - opened boxes of fish fillets and liver were soft to touch. Cooks and the Food Service manager (FSM) were interviewed during the tour and stated that the cooked, refrigerated roast beef was usually used for soup and should be kept for three days if not frozen and the salmon, chicken salad and eggplant should have been thrown out after three days. The executive chef was interviewed at the time of the above observation and stated there was a problem with the freezer since last month and that a service man came out to fix it. The executive chef stated that a part was ordered at the beginning of March, 2017 but it has not arrived. He stated that the freezer temperature fluctuated above zero degrees and that the staff did not report it today because it is an ongoing issue, not a new problem. When asked as to why the potentially hazardous foods continued to be held in the freezer, the executive chef stated that they are using the freezer as a refrigerator at this time. The FSM was interviewed on 3/22/17 at the time of the observation and stated that the freezer has not been working properly since the beginning of March. He stated that there was no way to tell how long foods were unfrozen. He stated that he notified the facility's maintenance department who then called the refrigeration company in the beginning of March. The FSM stated that the refrigeration company could not fix the freezer completely until the replacement part arrives. The FSM did not provide a response when asked as to why the potentially hazardous foods had not been removed. He stated that the freezer temperatures were above zero and that was unacceptable in maintaining foods in their frozen solid state. Facility temperature logs revealed the freezer temperatures ranged between 25 and 30 degrees Fahrenheit for a period of 15 days, from 3/5/17 to 3/20/17. It was not possible to determine how long the meats and other foods were in a thawed state. During further interview with the executive chef on 03/22/17 1:26 PM he stated that today he would use anything in the freezer depending on the date. He stated that he is using defrosted Italian sausage dated 3/17/17 in the soup today. He stated that, if the sausage was not frozen he would have used or discarded it by Monday 3/21/17. The chef stated that everything in the freezer was frozen on Sunday and he thought everything thawed on Monday. He then stated that not all of the items in freezer, including the sausage, were checked to see if they were frozen. The director of maintenance was interviewed on 3/22/17 at 4:00 PM regarding the facility's notification process when kitchen equipment needed repair. The director of maintenance stated that, if the facility was unable to fix the equipment, an outside vendor has to be called in to fix the equipment in question. When asked if the problem with the freezer is an ongoing problem, the director of maintenance stated that in the past month the freezer and the reach-in refrigerator were out a couple of times and they were repaired. He stated the problem was being addressed and he did not need to notify the administrator. He stated that he would make a recommendation to the administrator to replace the freezer if necessary but it was not necessary so he did not communicate to the administrator. He did not know that the freezer was not maintaining the proper temperatures after they were repaired. The director of maintenance stated that his staff or someone in the kitchen usually notifies him of the outcome of the repair. He stated that if the problem continues, the facility would rent a freezer. He stated the facility did not rent a freezer because the maintenance staff will try to fix the problem first. When asked to provide any evidence of preventive maintenance of the freezer, the director of maintenance stated he did not know when the last time any preventive maintenance was conducted. He stated he was not aware the temperatures of the freezer were that high and that he would suggest to the administrator to rent a freezer. He stated that it is unacceptable for the refrigerator and the freezer to be above acceptable temperatures. Freezer stored foods checked on 3/22/17 at 4:24 PM revealed: stuffed shells, 27 degrees, received 3/17/17; sword fish, 28 degrees, received 3/9/17 turkey burgers, 28 degrees, received 2/6/17 scrod, 28.6 degrees, dated 3/11/17 jumbo cheese ravioli, 28.5 degrees, dated 1/16/17; vegetable spring rolls 30.4 degrees undated/unopened. The FSD stated that We are working under the assumption that this is a refrigerator for the time being. The FSD stated that any of the food items that defrosted would be used in four days if in a cryovac package and within 72 hours if not in a cryovac package. The FSM was further interviewed on 3/22/17 at 4:35 PM and stated that the problem with the freezer has been going on since February 10 or 11. The FSM stated there was a frost build-up at the back of the freezer and they defrosted it. He stated the compressor and the temperature returned to normal but at times fluctuated to above zero. He further stated that on March 5, he noticed a spike in the temperature of the freezer. He stated he called an outside vendor who ran a defrost cycle and was waiting for a part to correct the problem. The FSM stated the freezer temperature continued to fluctuate between March 5 and March 20. He stated he called the vendor a few times during this time period and was told by the vendor that they were still waiting for the parts. The FSM stated that the freezer temperatures were not at acceptable range to maintain the frozen foods at their solid state. When asked to describe the facility's back-up plan, the FSM stated the facility has no back-up freezers. He stated that the unfrozen foods would be thrown away. Further inspection of the freezer on 3/22/17 at 5:00 PM revealed potentially hazardous and time controlled for safety foods still being held inside the freezer and their internal temperatures were recorded as follows: - Jumbo cheese ravioli, dated 1/16/17, 28.5 degrees F; - Raw short ribs wrapped in plastic wrap, dated 12/31/16, 28 degrees F; - Three duck breasts, dated 1/26/17, 32 degrees F; - Pureed eggplant dated 3/8/17, 30 degrees F; - Beef tenderloin tips, delivery date of 3/9/17, not frozen solid to touch; - Sword fish, dated 3/9/17, not frozen solid, 27 degrees F; - Package of beef for pepper steak dated 3/17/17 was soft to touch; - Uncooked liver dated 3/20/17, 29 degrees F; - Bag of blintzes, undated and was not frozen to touch; - Ahi Tuna, 38 degrees F; - Turkey burgers, labeled keep at 0 degrees, soft to touch, 28 degrees F. The following food items with temperatures ranging from 26 to 33 degrees F were additionally observed in the freezer on 3/22/17 from 6:00 PM to 7:15 PM and contained labels indicating to keep frozen, store at 0 degrees or below: scallops, beef for stew, raw peeled shrimps, flounder fillets, hamburgers, Cajun style sausage, short ribs, turkey burgers, raw chicken leg/thigh, raw chicken breast, tater tots, scones, chocolate-chip cookie dough, blueberry muffins, fudge brownies, pancakes, and waffles. The facility Administrator was interviewed on 03/22/17 at 5:15 PM and stated that he was not aware of any problems in the kitchen with freezer temperatures not being within the acceptable range of -10 degrees Fahrenheit (F) to 0 degrees F. The Administrator stated that the freezer service repair company had come to the facility the previous week and stated to him that parts were needed. The Administrator also stated at that time that the freezer was operating perfectly yesterday (3/21/2017). The administrator was unable to provide documented evidence for the service call to repair the freezer. During additional freezer inspection and food temperature checks on 3/22/17 at approximately 6:30 PM, the surveyor and FSM reviewed food package instructions for storage of frozen foods that directed to keep at 0 degrees F or less. The FSM stated that he thought 32 degrees or less was acceptable for freezer storage. The executive chef was interviewed further on 3/23/17 at 10:40 AM and stated he could not recall when the refrigeration company came in but was told that a part needed to be replaced for the freezer to be completely fixed so the freezer would be working properly below zero. Inconsistent with this statement, he also stated that roast beef and other items were not discarded because temperatures were at or below 32 degrees F. The administrator was interviewed again on 3/23/17 at 11:00 AM regarding his awareness of the problems with the freezer. The Administrator then stated that he actually first became aware of this issue on 3/22/17, after facility staff brought surveyor concerns regarding freezer temperatures to his attention. A representative from the nutrition company managing the facility kitchen was interviewed on 3/24/17 at 12:20 PM and stated that he was not aware that the freezer was not maintaining proper temperatures. He stated he does not routinely monitor the condition of the food service equipment. During a follow up interview on the same date at 3:11 PM, he stated that he set up a meeting with the FSM on 3/10/17 to check specific equipment including the reach-in refrigerator, the double deck oven, the ice machine and the island where the hot station is located, the steamer, the skillet and the small ice cream freezer. He stated that the freezer and the other refrigerators were not on the list of concerns. He further stated that if there was a malfunction of the freezer, the FSM would have made him aware. The Registered Dietitian (RD#1) from the nutrition company was interviewed on 3/24/17 at 2:25 PM and stated she is filling in for RD#2. She stated that she does not believe that the RD is responsible for monitoring the function of any equipment or food temperatures. RD#2 was interviewed by phone on 3/24/17 at 2:35 PM and stated she does not participate in running the food service department and that she had no knowledge that the freezer was not functioning properly. RD#2 stated that her role was strictly clinical and she collaborates with nursing about the residents' food preferences and consistency. Further interview with the administrator was conducted on 3/24/2017 at 2:00 PM. The Administrator stated that when a repair of essential kitchen equipment is needed, the food service company informs the facility maintenance staff. If the facility maintenance staff is unable to affect a repair, the facility director of maintenance would call the freezer repair company for repair of the equipment. The Administrator stated that he was informed of needed repairs of essential kitchen equipment by the director of maintenance and the food service manager on the day that one of the surveyors questioned them about the freezer temperatures on 3/22/17. The Administrator stated that he should have been notified by both directors immediately at the time when the freezer wasn't working. He stated that he does not ask the maintenance director and the food service manager of any problems in the kitchen and that he should start asking them on a regular basis about any issues in the kitchen. The FSM was interviewed further on 3/24/17 at 3:00 PM and stated that the problem with the freezer was reported to maintenance on the day the issue was noted either on 2/25/17 or 2/26/17. The FSM stated that the refrigeration company came in the following day and the issue was apparently resolved. He stated that the issue occurred again on 3/5/17. The FSM stated the freezer could not be fixed until the broken part is replaced. He stated that the freezer temperatures continued to fluctuate above zero and the part has not arrived as of this time. When asked if the administrator was informed of the problem with the freezer, the FSM stated he did not believe so. The FSM further stated he did not have any reason to contact the administrator. The FSM also stated he did not contact anyone from the nutrition company about the problem until the day of the survey. 2. Sanitary Conditions Sanitary conditions and food handling guidelines were not observed by dietary staff as follows on 3/22/17 between 9:30 AM - 7:00 PM: 9:27 AM Cook did not sanitize temperature probe and handled middle section with her bare hand when checking ice cream temperature; 10:15 AM Cook removed probe from her uniform pocket and tested temperature of sour cream without sanitizing; 10:02 AM Slicer with food debris, pieces of lettuce, crumbs, dried yellow spot; Cooks' area shelves/dish storage shelves/plate cover shelves with loose dried food particles, white colored spills, tacky surface to touch, dusty electrical equipment beneath in open, exposed area; Steamer loose/not properly fitting on one side near the wall with steam exuding and dripping, forming puddle on the floor; Two moderate to heavily soiled grates on the floor leaning against the wall next to steamer; 10:13 AM Undated, uncovered pitcher tomato juice, uncovered whipped cream, two open cans soda in reach-in refrigerator. Cook stated residents request less than full can at dinner. No thermometer in bread storage refrigerator and heavy layer of crumbs on bottom; 10:19 AM Ceiling vents dusty; Dried food debris and plastic wrap on freezer floor; 11:00 AM Dried food debris on mixer; Bouquet of flowers on metal tray in refrigerator next to boxes of spinach and arugula. (The FSM stated he did not know why they were in there should not be any flowers in there). Undated, uncovered chicken in pan with large amount of drippings; Undated cup of unidentified salad (possibly tuna); Undated bowl egg salad; Cook removed open package smoked salmon dated 3/17/17, wrapped in plastic wrap, relabeled 3/22/17 and replaced in freezer stating she uses it until it is used up. Expired container low fat cottage cheese dated 3/17/17; Metal container of unidentifiable salad dated 3/17/17. Cook stated did not know what it was. Undated metal container cooked bacon; Milk and butter mixture in metal pan dated 3/15/17. Cook stated used for mashed potatoes and usually kept 3 days. Metal container of black olives dated 2/28/17. 3/23/17 observations: 11:36 AM Front of compressor on ice machine not properly aligned, door not closing, duct tape in place, frost build-up, unprotected scoop inside. The lid of ice machine missing gaskets, misaligned, secured by plastic tie on one side, heavily soiled inside lid. The FSM stated that the ice machine was last drained and cleaned by dietary staff the second week of January and ice build -up was due to lack of air flow. All maintenance is performed in house. He was not aware of door issue and will contact maintenance. 12:17 PM Again observed that left wall of steamer (near wall) is not properly aligned with heavy steam escaping, and condensation that produced a puddle of water on the floor. 12:35 PM Two light fixtures in ice machine area without covers, one light fixture in dishwasher area with broken cover and a food stain that appears to be a dried splatter of orange food visually estimated to measuring 4x7 inches. Vent over condiment fridge and throughout kitchen ceiling are soiled and have accumulated dust, dirty ceiling tiles. Several ceiling tiles are in disrepair, walls are visibly soiled/dirty, stainless steel hand rails are visibly soiled with an accumulation of what appears to be dried liquids with moderate accumulation to touch (raised areas). 3/24/17 observations: 10:08 AM Again observed steamer remains in disrepair as evidenced by left side (wall side) not properly aligning, resulting in a heavy discharge of steam which condensed in a puddle of water on the floor. Staff placed a rubber mat over the area. 03/28/2017 observations: 10:40 AM Grease on long handled cleaning brush on top of the double deck convection oven, under hood and on ansul system pipe caps; Walls behind cooks' area soiled. The Regional Manager was interviewed on 3/28/17 at 12:20 PM and stated that cleaning schedules are not kept. They are discarded. There is no master schedule or log available for reviewing or referring to a cleaning schedule. The Regional Manager stated that there is a schedule for staff training for food safety and it is not being followed. . 3. Dining Observations A lunch meal observation was conducted on 3/22/17 at 1:00 PM. A food service worker (FSW #1) was observed touching the warming cart, the covers on the steam table, the refrigerator, and all the pans inside the warming cart with gloved hands and then touched the food contact surfaces of the plates without changing gloves. When questioned about why she didn't change her gloves, FSW #1 stated she just put the gloves on before she came into the room. The lunch menu included hamburgers with lettuce, tomato and onion. The buns for the hamburgers and all the vegetable toppings were handled by the FSW's potentially contaminated gloved hands. Three male servers and one female server were observed preparing trays for dining room service at 5:20 PM on 3/22/17 without wearing hairnets. When asked why they were not wearing hairnets they stated that they should be wearing them. During another lunch observation on 3/24/17, the chef was observed taking food temperatures. The chef rinsed a probe in running water, dried it with a paper towel and placed in food without effectively disinfecting the probe. The chef again rinsed the probe in running water, dried on his apron and inserted into food, then rinsed in running water and wiped off excess water with his gloved hand. A cook came into the service area with a pan of chicken. He proceeded to take a thermometer out of his pocket and checked the temperature of the food without first sanitizing the thermometer. The cook quickly left the food service area without reporting the temperature to anyone. At that time, the FSW checked the temperature of the chicken and it was 164 degrees. The chicken was sent back to the kitchen by the FSW to be reheated. The FSW stated the food should be reheated for 30 seconds to at least 165 degrees F. During the same lunch observation on 3/24/17 at 12:55 PM, FSW #2 was observed to wash his hands and then take a towel out of his back pocket to dry his hands. When asked why he was using that towel and not the paper towels (in the dispenser next to him), he stated he hadn't used his towel for anything yet. He then washed his hands again and used paper towels to dry them. FSW #2 was observed about to use a thermometer that was placed on the counter top to take food temperatures without sanitizing it first. The surveyor intervened and FSW #2 stated that he should have sanitized it with alcohol wipes. Following surveyor intervention, FSW #2 obtained alcohol wipes from a nursing staff member. There were no alcohol wipes available in the food service area to sanitize thermometers. A nutrition company personnel who was present during the dining observation stated that they used the last alcohol wipe in the kitchen. 415.14(h)

Based on observation, interview and record review during a recertification survey, the facility failed to ensure that essential equipment was maintained in safe operating condition to prevent potential harm to residents from food borne illness. Specifically, the facility's malfunctioning kitchen freezer was not effectively repaired in a timely manner to ensure that potentially hazardous foods (PHF) or temperature control for safety (TCS) foods were stored at frozen solid states until ready for use, in accordance with professional standards for food service safety, to prevent the potential for development of food borne illness. For a period of 15 days, from 3/5/17 to 3/20/17, the freezer temperatures ranged between 25 and 30 degrees Fahrenheit. Multiple meat items and other foods were stored during that time period and available for use, including uncooked brisket and cooked meat loaf dated 12/1/17 and 12/18/17, respectively. On 3/22/17, food items were noted to be thawed and food temperatures ranged from 28 to 38 degrees Fahrenheit. This resulted in immediate jeopardy potentially affecting all 14 residents of the facility. The findings are: Cross References: F371 - Food Procurement, Storage, Preparation and Serving Food = L F490 - Effective Administration / Resident Well-Being = L An initial tour of the facility kitchen was conducted on 3/22/17 between 9:20 AM - 11:00 AM. It was observed that the freezer's external thermometer gauge recorded 28 degrees Fahrenheit (F) and the internal temperature was 36 degrees. Multiple PHF/TCS foods found in the freezer, some undated, were soft to touch and were not in frozen solid states including, but not limited to: - uncooked brisket dated 12/1/16; - uncooked pork butt dated 12/12/16; - a piece of meat loaf dated 12/18/16; - lamb chops dated 1/1/17; - an expired unopened package of pancetta, with sell-by-date of 1/11/17; - uncooked duck breast dated 1/26/17 with a temperature of 32-33 degrees F; - a large cooked roast beef dated 1/30/17 with a temperature of 30 degrees F (the facility provided their own thermometer); - pureed eggplant dated 3/8/17 with a temperature of 30.5 degrees F; - beef tenderloin tips delivered on 3/9/17; - two pieces of salmon wrapped in plastic dated 3/16/17with a temperature of 32.5 degrees F; - jumbo stuffed shells with a temperature of 31.7 degrees F; - opened boxes of fish fillets and liver. The executive chef was interviewed at the time of the above observation and stated there was a problem with the freezer since last month and that a service man came out to fix the freezer. He stated that a broken freezer part was ordered at the beginning of March, 2017. He stated that the freezer temperature fluctuated above zero degrees and that the staff did not report it today because it is an ongoing issue, not a new problem. The Food Service Manager (FSM) was also interviewed on 3/22/17 at the time of the observation and stated that the freezer has not been working properly since the beginning of March. He stated that he notified the facility's maintenance department who then called the refrigeration company in the beginning of March and they are still waiting for the replacement part up to this time. He stated that the freezer temperatures were above zero and that was unacceptable in maintaining foods in their frozen solid state. Facility temperature logs revealed the freezer temperatures ranged between 25 and 30 degrees Fahrenheit for a period of 15 days, from 3/5/17 to 3/20/17. It was not possible to determine how long the meats and other foods were in a thawed state. The director of maintenance was interviewed on 3/22/17 at 4:00 PM regarding the facility's notification process when kitchen equipment needed repair. He stated that, if the facility was unable to fix the equipment, an outside vendor has to be called in to fix the equipment in question. When asked if the problem with the freezer is an ongoing problem, he stated that in the past month the freezer and the reach-in refrigerator were out a couple of times and they were repaired. He stated the problem was being addressed and he did not need to notify the administrator. He stated that he would make a recommendation to the administrator to replace the freezer if necessary but it was not necessary so he did not communicate to the administrator. He stated he did not know that the freezer was not maintaining the proper temperatures after they were repaired. The director of maintenance stated that his staff or someone in the kitchen usually notifies him of the outcome of the repair. He stated that if the problem continues, the facility would rent a freezer. He stated the facility did not rent a freezer because the maintenance staff will try to fix the problem first. When asked to provide any evidence of preventive maintenance of the freezer, the director of maintenance stated he did not know when the last time any preventive maintenance was conducted. He stated he was not aware the temperatures of the freezer were that high and that he would suggest to the administrator to rent a freezer. He stated that it is unacceptable for the refrigerator and the freezer to be above acceptable temperatures. The FSM was further interviewed on 3/22/17 at 4:35 PM and stated that the problem with the freezer has been going on since February 10 or 11. The FSM stated there was a frost build-up at the back of the freezer and they defrosted it. He stated the compressor and the temperature returned to normal but at times fluctuated to above zero. He further stated that on March 5, he noticed a spike in the temperature of the freezer. He stated he called an outside vendor who ran a defrost cycle and was waiting for a part to correct the problem. The FSM stated the freezer temperature continued to fluctuate between March 5 and March 20. He stated he called the vendor a few times during this time period and was told by the vendor that they were still waiting for the parts. The FSM stated that the freezer temperatures were not at acceptable range to maintain the frozen foods at their solid state. When asked to describe the facility's back-up plan, the FSM stated the facility has no back-up freezers. He stated that the unfrozen foods would be thrown away. Further inspection of the freezer on 3/22/17 at 5:00 PM revealed potentially hazardous and time controlled for safety foods still being held inside the freezer, not frozen solid, with internal temperatures recorded as follows: - Jumbo cheese ravioli, dated 1/16/17, 28.5 degrees F; - Three duck breasts, dated 1/26/17, 32 degrees F; - Pureed eggplant, dated 3/8/17, 30 degrees F; - Uncooked liver, dated 3/20/17, 29 degrees F; - Sword fish, dated 3/9/17, 27 degrees F; - Package of beef for pepper steak, dated 3/17/17; - Beef tenderloin tips, delivery date of 3/9/17; - Bag of blintzes, undated; - Ahi Tuna, 38 degrees F; - Turkey burgers, 28 degrees F. The following food items with temperatures ranging from 26 to 33 degrees F were additionally observed in the freezer on 3/22/17 from 6:00 PM to 7:15 PM and contained labels indicating to keep frozen, store at 0 degrees or below: scallops, beef for stew, raw peeled shrimps, flounder fillets, hamburgers, Cajun style sausage, short ribs, turkey burgers, raw chicken leg/thigh, raw chicken breast, tater tots, scones, chocolate-chip cookie dough, blueberry muffins, fudge brownies, pancakes, and waffles. The facility Administrator was interviewed on 03/22/17 at 5:15 PM and stated that he was not aware of any problems in the kitchen with freezer temperatures not being within the acceptable range of -10 degrees Fahrenheit (F) to 0 degrees F. The Administrator stated that the freezer service repair company had come to the facility the previous week and stated to him that parts were needed. The Administrator also stated at that time that the freezer was operating perfectly yesterday (3/21/2017). The administrator was unable to provide documented evidence for the service call to repair the freezer. The executive chef was interviewed further on 3/23/17 at 10:40 AM and stated he could not recall when the refrigeration company came in but were told that a part needed to be replaced for the freezer to be completely fixed so the freezer would be working properly below zero. The administrator was interviewed again on 3/23/17 at 11:00 AM regarding his awareness of the problems with the freezer. The Administrator then stated that he actually first became aware of this issue on 3/22/17, after facility staff brought surveyor concerns regarding freezer temperatures to his attention. A representative from the nutrition company managing the facility kitchen was interviewed on 3/24/17 at 12:20 PM and stated that he was not aware that the freezer was not maintaining proper temperatures. He stated he does not routinely monitor the condition of the food service equipment. During a follow up interview on the same date at 3:11 PM, he stated that he set up a meeting with the FSM on 3/10/17 to check specific equipment including the reach-in refrigerator, the double deck oven, the ice machine and the island where the hot station is located, the steamer, the skillet and the small ice cream freezer. He stated that the freezer and the other refrigerators were not on the list of concerns. He further stated that if there was a malfunction of the freezer, the FSM would have made him aware. The Registered Dietitian (RD#1) from the nutrition company was interviewed on 3/24/17 at 2:25 PM, and stated she is filling in for RD#2. She stated that she does not believe that the RD is responsible for monitoring the function of any equipment or food temperatures. RD#2 was interviewed by phone on 3/24/17 at 2:35 PM and stated she does not participate in running the food service department and that she had no knowledge that the freezer was not functioning properly. RD#2 stated that her role was strictly clinical and collaborates with nursing about the residents' food preferences and consistency. Further interview with the administrator was conducted on 3/24/2017 at 2:00 PM. The Administrator stated that when a repair of essential kitchen equipment is needed, the food service company informs the facility maintenance staff. If the facility maintenance staff is unable to affect a repair, the facility director of maintenance would call the freezer repair company for repair of the equipment. The Administrator stated that he was informed of needed repairs of essential kitchen equipment by the director of maintenance and the food service manager on the day that one of the surveyors questioned them about the freezer temperatures on 3/22/17. The Administrator stated that he should have been notified by both directors immediately at the time when the freezer wasn't working. He stated that he does not ask the maintenance director and the food service manager of any problems in the kitchen and that he should start asking them on a regular basis about any issues in the kitchen. The FSM was interviewed further on 3/24/17 at 3:00 PM and stated that the problem with the freezer was reported to maintenance on the day the issue was noted either on 2/25/17 or 2/26/17. The FSM stated that the refrigeration company came in the following day and the issue was apparently resolved. He stated that the issue occurred again on 3/5/17. The FSM stated the freezer could not be fixed until the broken part is replaced. He stated that the freezer temperatures continued to fluctuate above zero and the part has not arrived as of this time. When asked if the administrator was informed of the problem with the freezer, the FSM stated he did not believe so. The FSM further stated he did not have any reason to contact the administrator. The FSM also stated he did not contact anyone from the nutrition company about the problem until the day of the survey. The facility policy and procedure on Equipment Failure and Maintenance, effective 6/12/15 and reviewed on 1/12/17, stated that the facility must follow the manufacturer's instructions for preventive maintenance and care of the equipment. In the event of equipment failure, this policy and procedure further stated that the equipment must be turned off or unplugged and all the food must be removed. According to the management agreement dated 11/01/16, entered by the facility and the nutrition company that is operating and managing the facility's food service facilities and related activities, the facility shall furnish, maintain and repair the equipment required by the nutrition company to carry out its obligations in receiving, preparing and serving food. 415.5(e)(1)(2)

Based on record review and interview conducted during a recertification survey, the facility failed to provide operative oversight to ensure that an effective system was in place to communicate malfunction of equipment essential to maintain health, safety and the highest practicable well-being of residents. Food service and maintenance staff did not report to the administrator that the kitchen freezer was malfunctioning and was not effectively repaired in a timely manner to ensure that potentially hazardous foods (PHF) and temperature control for safety (TCS) foods were stored at frozen solid states until ready for use, in accordance with professional standards for food service safety, to prevent the potential for development of food borne illness. This resulted in immediate jeopardy potentially affecting all the residents of the facility. The findings are: Cross References: F371 - Food Procurement, Storage, Preparation and Serving Food = L F465 - Essential Equipment = L According to facility temperature logs, for a period of 15 days, from 3/5/17 to 3/20/17, the kitchen freezer temperatures ranged between 25 and 30 degrees Fahrenheit. Multiple meat items and other foods were stored during that time period and available for use including uncooked brisket and cooked meat loaf dated 12/1/17 and 12/18/17, respectively. On 3/22/17, these numerous food items stored in the freezer were noted to be thawed and food temperatures ranged from 28 to 38 degrees Fahrenheit. The Food Service Manager (FSM) was also interviewed on 3/22/17 at the time of the observation and stated that the freezer has not been working properly since the beginning of March. He stated that he notified the facility's maintenance department who then called the refrigeration company in the beginning of March and they are still waiting for the replacement part up to this time. He stated that the freezer temperatures were above zero and that was unacceptable in maintaining foods in their frozen solid state. The director of maintenance was interviewed on 3/22/17 at 4:00 PM regarding the facility's notification process when kitchen equipment needed repair. He stated that, if the facility was unable to fix the equipment, an outside vendor has to be called in to fix the equipment in question. When asked if the problem with the freezer is an ongoing problem, he stated that in the past month the freezer and the reach-in refrigerator were out a couple of times and they were repaired. He stated the problem was being addressed and he did not need to notify the administrator. He stated that he would make a recommendation to the administrator to replace the freezer if necessary but it was not necessary so he did not communicate to the administrator. He stated he did not know that the freezer was not maintaining the proper temperatures after they were repaired. The director of maintenance stated that his staff or someone in the kitchen usually notifies him of the outcome of the repair. He stated that if the problem continues, the facility would rent a freezer. He stated the facility did not rent a freezer because the maintenance staff will try to fix the problem first. The facility Administrator was interviewed on 03/22/17 at 5:15 PM and stated that he was not aware of any problems in the kitchen with freezer temperatures not being within the acceptable range of -10 degrees Fahrenheit (F) to 0 degrees F (in accordance with professional standards for food service safety, to prevent the potential for development of food borne illness). The Administrator stated that the freezer service repair company had come to the facility the previous week and stated to him that parts were needed. The Administrator also stated at that time that the freezer was operating perfectly yesterday (3/21/17). The administrator was unable to provide documented evidence for the service call to repair the freezer. The administrator was interviewed again on 3/23/17 at 11:00 AM regarding his awareness of the problems with the freezer. The Administrator then stated that he actually first became aware of the issue with the freezer on 3/22/17, after facility staff brought surveyor concerns regarding freezer temperatures to his attention. Further interview with the administrator was conducted on 3/24/17 at 2:00 PM regarding the facility policy and procedure for repair of essential equipment in the kitchen. The Administrator stated that when a repair of essential kitchen equipment is needed, the food service company informs the facility maintenance staff. If the facility maintenance staff is unable to affect a repair, the facility director of maintenance would call the freezer repair company for repair of the equipment. The Administrator stated that he was informed of needed repairs of essential kitchen equipment by the director of maintenance and the food service manager on the day that one of the surveyors questioned them about the freezer temperatures on 3/22/17. The Administrator stated that he should have been notified by both directors immediately at the time when the freezer wasn't working. He stated that he does not ask the maintenance director and the food service manager of any problems in the kitchen and that he should start asking them on a regular basis about any issues in the kitchen. The FSM was interviewed further on 3/24/17 at 3:00 PM and stated that the problem with the freezer was reported to maintenance on the day the issue was noted either on 2/25/17 or 2/26/17. The FSM stated that the refrigeration company came in the following day and the issue was apparently resolved. He stated that the issue occurred again on 3/5/17. The FSM stated the freezer could not be fixed until the broken part is replaced. He stated that the freezer temperatures continued to fluctuate above zero and the part has not arrived as of this time. When asked if the administrator was informed of the problem with the freezer, the FSM stated he did not believe so. The FSM further stated he did not have any reason to contact the administrator. The FSM also stated he did not contact anyone from the nutrition company about the problem until the day of the survey. 415.26

Based on observation and interview conducted during a recertification survey, the facility did not ensure that bed linens available for resident use were in good condition. Specifically, bed linens in 3 out of 14 rooms on one of one resident unit were found to be threadbare, stained and had multiple holes in them which was evident during environmental review. The findings are: An environmental tour of the facility was conducted on 3/28/17 at 1:45 PM, and the following conditions were observed. - room [ROOM NUMBER], the fitted bed sheet and bed spread were threadbare, had discolored spots and multiple holes; - room [ROOM NUMBER], the fitted bed sheet was threadbare and had multiple holes; - room [ROOM NUMBER], the fitted bed sheet and bed spread were threadbare and had multiple holes. The Certified Nursing Aide (CNA#1) assigned to room [ROOM NUMBER] was interviewed on 3/28/17 at 1:47 PM and stated that the resident's bed linens had holes in them which had been a problem. CNA#2 was interviewed on 3/28/17 at 1:50 PM and stated that a lot of residents' bed linens have holes in them. CNA#2 further stated that she had reported this problem to the housekeeping director. The Director of Nursing, who was present during the tour, was interviewed on 3/28/17 at 1:55 PM and stated that she was not aware of any bed linen issues. The Director of Housekeeping (DH) was interviewed via telephone on 3/28/17 at 2:45 PM and stated that the CNAs notified him about the bed linens having holes in November 2016, and the DH had actually seen the problem. The DH stated that in December 2016 he spoke with the regional manager of the outside company handling the linens and that the problems had improved. The DH further stated that recently, the problem reoccurred and that he planned to contact the new company manager about the linen issues. 415.5(h)(3)

Based on observation and interview conducted during a recertification survey, the facility did not ensure that the residents' environment remained as free from potential accident hazards as is possible in 7 out of 14 rooms (203, 205, 208, 210, 212, 217, and 219) occupied by residents. Specifically, multiple wardrobe closets were wobbly and were not securely anchored to the wall to prevent from being accidentally knocked over. The findings are: Environmental tours of the facility were conducted and the following conditions were observed: a. 3/22/17 at 12:00 PM The wardrobe closets in rooms 203, 205, 208, 210, and 212, were observed to be wobbly with no device was noted to stabilize them. In room 219, brackets were found on the wall but were not attached to the wardrobe closet to prevent it from toppling over. b. 3/23/17 at 9:00 AM In room 217, there were brackets on the wall that were not attached to the wardrobe closet which was slightly wobbly at the time of the time of observation. The director of plant operations (DPO) was interviewed on 3/22/17 at 12:00 PM and stated he was not aware of any problems with residents' wardrobe closets. The DPO stated that environmental rounds are made monthly but he was not sure if closets were checked. The DPO stated that all wardrobe closets should have brackets that should have been attached. 415.12(h)(1)

Based on observation, interview and record review during a recertification survey, the facility did not evaluate use of a positioning device (cervical collar) for effectiveness, or as a possible source of discomfort/pain, or provide alternative solutions to minimize discomfort from use of the cervical collar for 1 of 1 resident reviewed for positioning (Resident #13). The findings are: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan for Pain/Alteration in Comfort dated 3/13/17 indicated the resident had pain related to [MEDICAL CONDITION]. Interventions included: assess and document pain characteristics, observe activity level, observe for depression, administer medications, provide rest periods, teach deep breathing relaxation techniques and adjust daily schedule PRN (as needed) per tolerance. The Five-Day Minimum Data Set (MDS; a resident assessment tool) of 3/20/17 identified that the resident received special treatments, procedures and programs including Speech Therapy, Occupational Therapy and Physical Therapy during this assessment period. The resident was observed and interviewed on 3/22/17 at 10:00 AM, sitting in a chair in her room with her head and neck leaning to her right side. Occasionally, the resident was observed to lift her head up during the interview. Most of the time, she would lean her head to the right side. The resident was further observed on 3/23/17 at 4:00 PM. The resident was walking with an aide and was wearing a cervical collar to hold her head up. When asked how the collar feels, the resident stated that it feels like it's making my eyes pop out. She stated she had been using the collar since admission to the facility and it was uncomfortable. The resident stated sometimes it's more comfortable than others. Further review of the resident's care plans showed no documented evidence that use of the cervical collar as a possible source of pain was addressed. The Occupational Therapy notes for the certification period 3/15/17 - 4/11/17 indicated an entry by the Occupational Therapist that the resident exhibits physical deficits with ADLs and decreased AROM (Active Range of Motion) of neck. There was no documented evidence that an assessment, planning or evaluation was conducted to address the use of the cervical collar or an alternate method or device to minimize the resident's discomfort. The Occupational Therapist (OT) was interviewed, along with the Director of Rehabilitation, on 3/24/16 at 2:45 PM regarding what is being done for the resident in Occupational Therapy (OT). The OT stated that she is working with the resident to improve her ability to perform activities of daily living (ADLs) with less pain and working on her right sided weakness. When asked about the cervical collar, the OT stated the resident brought it from home and it was not something that was issued at the nursing home. When asked further about the resident not feeling comfortable from using the cervical collar, the OT stated she doesn't think the resident likes it and that there isn't anything they can do to make it more comfortable for the resident. The director of rehabilitation then stated that any other device they might use would restrict the resident's mobility or not be appropriate for her, such as a stiff neck that would hold her head up. The Director of Nursing (DON) was interviewed on 3/28/17 at 10:30 AM and stated the cervical collar should have been evaluated by OT to determine if it was providing any benefit to the resident. 415.16(a)

Based on observation, interview and record review during a recertification survey, the facility did not ensure that drugs and biologicals were stored in locked compartments. Specifically, the emergency box containing medications to be used in the event of an emergency was observed to be unlocked. This was evident in one of one medication rooms. The findings are: During a review of the medication storage room, it was noted that the emergency box was unlocked. When asked about the unlocked box the RN medication nurse stated at 12:45 PM on 3/22/17 that it was locked. The RN then observed the plastic tie was not locking the box but attached to the plastic sleeve that held the list of medications found in the box and stated she would look inside to see if anything was missing. The RN stated she didn't think anything was missing but just to be sure she would put a red plastic tie on the box and send it back to the pharmacy to make sure it is complete. In an interview with the Director of Nursing on 3/23/17 at 10:45 AM regarding the emergency box that was not locked, the Director of Nursing stated that it's not supposed to be locked. She stated that it is not a swing box, meaning the entire box isn't taken out and sent to the pharmacy to replenish the medications. She stated that, for this box of medications, when a medication is used a form is filled out and faxed to the pharmacy identifying the medication that was used. The pharmacy is also notified by phone at that time. The medication is delivered to the facility with the next delivery. She further stated they get deliveries a couple of times per day. Review of the policy for Emergency Box, Antibiotic Box and Stat Orders indicated the following: After a box is opened the nurse will complete a resident specific usage form (E Box Reorder) indicating the resident name, date & time drug was used, and the quantity used. This form is placed inside the E Box. The nurse will follow one of the following procedures: Return the opened box (with completed sheet inside) to the Nursing Office and obtain a locked E Box. The opened box will be returned to the pharmacy for box replacement. OR Submits a form to the pharmacy or calls pharmacy to have the medication and new lock sent for replacement by the nursing supervisor. The supervisor replaces the medication into the box, updates the expiration date on the content list and locks the box. The RN medication nurse and the Director of Nursing were interviewed together on 3/23/17 at 12:00 PM. At that time the emergency box was noted to be locked. They stated that the night shift is supposed to check the box to see if there are any expired medications. If so, they would fax the information to the pharmacy and leave the box unlocked until the medications were delivered. The nurse who receives the medication is supposed to sign for the medications and lock the box. The box was then opened and the form on top identified 2 medications that had expired, the antibiotics Bactrim and Keflex. They checked the box to see if the expired medications had been replaced, and they had. They stated that the nurse probably forgot to lock the box when the medications were replaced. In addition, there was no documented evidence containing the signature of the nurse who received and replaced the medications. 415.18(d)

Based on record review and interview, the facility did not ensure that assessments and recommendations of the psychologist were available and utilized by the interdisciplinary team in order to plan and provide care to promote the highest practicable mental and psychological well-being for one of one resident reviewed for psychological services (Resident #16). The findings are: Resident #16 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of current Physician order [REDACTED]. The Director of Nursing (DON) was interviewed on 4/11/16 at 1:30 PM and stated that she would contact the psychologist regarding her notes. The psychologist was interviewed by telephone on 4/12/16 at 1:45 PM and stated that she had provided the notes to the unit on the morning of 4/12/16 for filing. She further stated that she had previously provided notes to the unit three weeks earlier for filing and was unable to explain why those notes were not in the clinical record. The resident's record was then re-reviewed and the Psychological Notes were not present dating from 2/1/16 through 4/5/16. 415.12

Based on observations and interviews during the recent recertification survey, the facility did not ensure that food was being stored according to professional standards of practice. The findings are: During the initial tour of the kitchen on 4/8/16 at 9:00 AM the following observations were made: The temperature of a reach-in refrigerator next to the stove was 58 degrees. Inside were three boxes of salmon and a full pan of brisket. In an interview with the cook at that time he stated they don't really use that refrigerator and moved all the items to the walk in refrigerator. The reach-in refrigerator/freezer next to a preparation sink had three pans of food in the refrigerator section that were not labled and dated. There was also a Boston cream pie with part of the frosting scraped off, uncovered and exposed. The reach-in freezer had a bag of rolls that was ripped open exposing the rolls to freezer burn. In the walk-in freezer, multiple boxes of food were being stored on the floor. In the walk-in produce cooler, several boxes of vegetables were being stored on the floor. In an interview with the Food Service Director at 11:00 AM on the same day, he stated that there was a double delivery sent from the vendor. When asked why the double delivery was accepted he stated, I wasn't here. In a second walk-in refrigerator there were two bags of cheese cubes (cheddar and Swiss) opened undated and not wrapped, exposing the cheese. . The refrigerator on the resident unit, where food is stored and served was observed at 10:20 AM on 4/8/16. There were two bowls of unlabeled and undated prepared tuna salad and an undated tuna salad plate. The Food Service Worker was interviewed on 4/8/16 at 10:30 AM and stated that the tuna salad plate was for a resident from the day before, who had gone out for an appointment. She stated that she was saving it for when the resident came back but shift was over before the resident returned. She stated that the resident apparently decided not to have the salad plate. She added she would have dated the plate if she had been there. When asked about the bowls of tuna, she was unsure where they came from and how long they had been there and removed them from the refrigerator. A second kitchen observation was made on 4/11/16 at 2:30 PM. There were still boxes of food being stored on the floor in the walk-in freezer. In an interview with the Food Service Director at that time, he stated that they just received a delivery and did not get a chance to put it away. 415.14(h)