Life Care Center Of The North Shore

F-F842

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 10 225529 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225529 B. Wing 04/03/2025

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

Life Care Center of the North Shore 111 Birch Street Lynn, MA 01902

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

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

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

Level of Harm - Minimal harm or 45763 potential for actual harm Based on observation and interviews, the facility failed to serve food that was palatable, and at a safe and Residents Affected - Some appetizing temperature, on three out of three units.

Findings include:

Review of a blank Test Tray Audit form indicated that the meal cart should be served within 15-20 minutes, that the temperature for cold foods should be less than 50 degrees Fahrenheit and the temperature for hot food should be greater than 120 degrees Fahrenheit.

During the initial tour of the facility on 4/1/25 the surveyors met with residents; eleven residents voiced dissatisfaction with the temperature and/or taste of the food served at the facility.

During the resident group meeting on 4/2/25 at 10:32 A.M. the surveyors met with residents; five out of five residents said the food was often cold when delivered.

On 4/2/25 at 8:00 A.M. the surveyor observed staff calibrating the thermometers to be used for test trays.

On 4/2/25 at 8:24 A.M., the Oceanview unit food truck arrived at the resident care unit. After all resident trays were served the surveyor received the test tray at 8:50 A.M., 26 minutes after the truck had arrived. The following was recorded and observed:

- Cream of wheat was 100 degrees Fahrenheit, tasted cold, not hot, and bland.

- Scrambled eggs were 108 degrees Fahrenheit and tasted cool not hot.

- Toast was 90 degrees Fahrenheit, was soggy and tasted cold.

- Cheesy hashbrowns were 110 degrees Fahrenheit, had good flavor but tasted lukewarm, not hot.

- Milk was 58 degrees Fahrenheit and tasted warm, not cold.

- Orange juice was 60 degrees Fahrenheit and tasted warm, not cold.

On 4/2/25 at 8:38 A.M. the Hillview unit food truck arrived at the resident care unit. After all resident trays were served the surveyor received the test tray at 8:58 A.M., 20 minutes after the truck had arrived. The following was recorded and observed:

- Scrambled eggs were 120 degrees Fahrenheit, tasted warm, not hot and were not seasoned.

- Cheesy hashbrowns were 122 degrees Fahrenheit and tasted warm, not hot.

- Toast was 110 degrees Fahrenheit and tasted warm, the toast had a soggy texture.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 10 225529 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225529 B. Wing 04/03/2025

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

Life Care Center of the North Shore 111 Birch Street Lynn, MA 01902

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

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

F 0804 - Juice was 51 degrees Fahrenheit and tasted cool not cold.

Level of Harm - Minimal harm or - Milk was 46 degrees Fahrenheit and tasted cold. potential for actual harm

On 4/2/25 at 8:30 A.M., the Garden view unit food truck arrived at the resident care unit, the surveyor Residents Affected - Some observed food was served on paper products. After all resident trays were served the surveyor received the test tray at 8:55 A.M., 25 minutes after the truck had arrived, and the following was recorded and observed:

- Oatmeal was 130 degrees and tasted warm, not hot.

- Scrambled eggs were 105 degrees Fahrenheit, tasted cool not hot and were bland.

- Cheesy hashbrowns were 110 degrees Fahrenheit and tasted warm not hot.

- Toast was 80 degrees Fahrenheit and was soggy.

- Milk was 50 degrees Fahrenheit.

- Juice was 40 degrees Fahrenheit.

During interviews on 4/2/25 at 9:05 A.M. and 4/3/25 at 8:30 A.M. the Food Service Director (FSD) said that her expectation for how quickly the meal cart was served and the acceptable temperatures for cold and hot foods was consistent with the parameters outlined on the Test Tray Audit form. The FSD said the Garden view meals were served using paper products due to a Norovirus outbreak.

During an interview on 4/2/25 at 2:20 P.M. the Registered Dietitian said she would expect hot food to be at least 140 degrees Fahrenheit when residents receive their trays.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 225529 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225529 B. Wing 04/03/2025

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

Life Care Center of the North Shore 111 Birch Street Lynn, MA 01902

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

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

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45763

Residents Affected - Some Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that food was dated in the main kitchen and unit kitchenettes, and that raw chicken was not stored above ready-to-eat food.

Findings include:

Review of the facility's policy titled Food Safety, revised [DATE REDACTED], indicated, but was not limited to, the following:

- Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth.

- Pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary (NSF) container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). 'Use by date' is noted on the label or product when applicable.

- All cooked and ready-to-eat food is stored above all raw food.

- Leftovers are dated properly and discarded after 72 hours unless otherwise indicated.

- Frozen, raw meat that is placed in a cooler is in a pan and labeled with pulled and use by dates.

Review of the facility's policy titled Food from Outside Sources, reviewed [DATE REDACTED], indicated, but was not limited to, the following:

- Adhere to expiration date on prepackaged food items; Items should be discarded if past expiration date.

- Foods that have been partially eaten (leftovers) should not be stored in the communal refrigerator but may be stored in a resident's personal refrigerator.

On [DATE REDACTED] at 7:08 A.M. the surveyor made the following observations during the initial walkthrough of the main kitchen:

- Two bags of raw chicken stored on the top tray on a rack in the walk-in refrigerator. The bags of chicken were open, undated, and were above a tray of cooked pork and ready-to-eat deli-meat.

- Two sandwiches wrapped but undated in the walk-in refrigerator.

- A bag of shredded cheese open but undated in the walk-in refrigerator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 225529 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225529 B. Wing 04/03/2025

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

Life Care Center of the North Shore 111 Birch Street Lynn, MA 01902

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

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

F 0812 - A container of fried food, undated and unlabeled in the walk-in refrigerator.

Level of Harm - Minimal harm or - A container of pasta salad open but undated in the walk-in refrigerator. potential for actual harm - American cheese open but undated in the walk-in refrigerator. Residents Affected - Some - Salami partially wrapped and undated in the walk-in refrigerator.

- Deli turkey open and partially wrapped but undated in the walk-in refrigerator.

- A container of thickened dairy drink open and dated ,d+[DATE REDACTED] in the reach-in refrigerator.

- A container of vegetable juice open with no use-by date in the reach-in refrigerator.

- A container of cranberry juice open but undated in the reach-in refrigerator.

On [DATE REDACTED] at 7:38 A.M. the surveyor made the following observations in the Hillview kitchenette refrigerator:

- An open apple juice dated ,d+[DATE REDACTED].

- An open orange juice dated ,d+[DATE REDACTED].

- An open cranberry juice, undated.

On [DATE REDACTED] at 7:43 A.M., the surveyor made the following observations in the 4th view kitchenette refrigerator:

- Smoked cooked salami open and wrapped in a black plastic bag, undated.

- An egg salad sandwich undated.

- Two open containers of apple juice dated ,d+[DATE REDACTED].

- A brown paper bag containing leftover food dated ,d+[DATE REDACTED].

- A plastic cup containing leftover food, undated.

- A brown paper bag with three containers of leftover food inside, labeled with a resident name but undated.

On [DATE REDACTED] at 8:12 A.M. the surveyor made the following observations in the Garden view kitchenette refrigerator:

- A half-gallon of whole milk with an expiration date of [DATE REDACTED]

- A half-gallon of skim milk with an expiration date of [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 225529 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225529 B. Wing 04/03/2025

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

Life Care Center of the North Shore 111 Birch Street Lynn, MA 01902

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

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

F 0812 During an interview on [DATE REDACTED] at 8:13 A.M. Certified Nursing Aide #1 said the expired milk should not be in

the fridge. She said the kitchen comes every day to check the dates and organize the kitchen and they Level of Harm - Minimal harm or should have removed it once it expired. potential for actual harm

During an interview on [DATE REDACTED] at 7:19 A.M. the Assistant Food Service Director said the raw chicken should Residents Affected - Some not have been stored above the cooked pork and that all prepared and open food should be wrapped and dated.

During interviews on [DATE REDACTED] at 7:25 A.M. and [DATE REDACTED] at 7:37 A.M. the Food Service Director (FSD) said all open and prepared food items should be dated and discarded after three days, including in the kitchenette refrigerators; the FSD said undated and expired foods should be discarded.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 225529 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225529 B. Wing 04/03/2025

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

Life Care Center of the North Shore 111 Birch Street Lynn, MA 01902

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

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

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49880

Residents Affected - Few Based on record review and interview, the facility failed to maintain complete and accurate medical records. Specifically,

1. During a gastrointestinal (GI) outbreak on the Garden View Unit, the facility failed to document symptoms exhibited by 16 out of 19 residents with a GI illness.

2. For one Resident (#43) out of a total sample of 29 residents, nursing documented they obtained blood pressure from his/her left arm when they did not.

Findings include:

Review of the facility policy, titled Nursing Documentation, reviewed September 2024, indicated, but was not limited to, the following:

- The medical record must also reflect the resident's condition, and the care and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team.

On 4/1/25 at 7:23 A.M., the Director of Nurses (DON) said that there was a current Norovirus outbreak in the facility that started over the weekend, but was not sure how many residents were affected.

Review of the LTC (Long Term Care) Acute Gastroenteritis Surveillance Line List, dated 4/1/25, that was provided to the surveyor on 4/1/25 indicated that 19 residents were exhibiting a combination of symptoms that included nausea, vomiting and diarrhea. Further review of the line list indicated that the first resident began with symptoms on 3/19/25 and the most recent began on 3/30/25.

Review of the medical records for all 19 residents indicated on the line list failed to indicate any documentation regarding GI symptoms for 16 out of 19 residents.

During an interview on 4/3/25 at 7:59 A.M., Nurse #2 said if a resident was experiencing GI symptoms (nausea, vomiting and diarrhea) it should be documented in the nurses' notes, and if symptoms persisted then it should be reported to the physician and documented.

During an interview on 4/3/25 at 8:10 A.M., the Minimum Data Set (MDS) Nurse said that residents began to experience symptoms last week, and that the GI illness really blew up over the weekend. She said that residents with symptoms were not tested for Norovirus. She said that residents were experiencing more vomiting than diarrhea. She said that the nurses on the floor should be documenting symptoms and interventions provided for the residents during this time and anything that happens on their shift in the medical record. She said she would consider the GI illness a change in condition where documentation would be necessary. She said she would expect that nurses are assessing and documenting hydration status of a resident with a GI illness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 225529 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225529 B. Wing 04/03/2025

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

Life Care Center of the North Shore 111 Birch Street Lynn, MA 01902

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

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

F 0842 During an interview on 4/3/25 at 8:21 A.M., The Infection Control Nurse said that nursing staff should be documenting all symptoms of the GI illness in the medical record, but she said that she reviewed the Level of Harm - Minimal harm or documentation and there was no documentation regarding symptoms. She said that the GI illness Blew up potential for actual harm over the weekend, but she was not called or notified of it until she returned to work on Monday. She said that nurses should be assessing and documenting hydration status for residents with GI symptoms, but they were Residents Affected - Few not.

During an interview on 4/3/25 at 9:41 A.M., the Director of Nurses said that residents who were exhibiting symptoms of GI illness were experiencing what she would consider a change in condition. She said that symptoms and assessments of the residents should have been documented in the medical records of the residents, but they were not.

45763

2. Resident #43 was admitted to the facility in June 2024 with a diagnosis of end stage renal disease.

Review of the Minimum Data Set (MDS), dated [DATE REDACTED], indicated Resident #43 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact

Review of Resident #43's active physician orders indicated the following order:

- Dialysis patient: Receives dialysis at dialysis center Monday Wednesday Friday. Do not take BP (blood pressure) on LEFT arm with fistula/shunt.

Review of Resident #43's blood pressure readings indicated nursing obtained his/her blood pressure on his/her left arm on the following dates: 2/1/25, 2/2/25, 2/8/25, 2/9/25, 2/15/25, 2/18/25, 2/22/25, 3/1/25, 3/3/25, 3/8/25, 3/9/25, 3/15/25, 3/16/25, 3/17/25, 3/22/25, 3/23/25, 3/29/25, 3/30/25.

During an interview on 4/2/25 at 10:50 A.M. Resident #43 said staff only use his/her right arm to take blood pressure readings, never his/her left arm.

During an interview on 4/2/25 at 10:57 A.M., Unit Manager #1 said Resident #43's left arm should not be used to take blood pressure readings as the Resident had a dialysis fistula on that arm. Unit Manager #1 Said the nurses had documented that the blood pressure was taken using Resident #43's left arm in error as

they only use the Resident's right arm.

During an interview on 4/2/25 at 3:06 P.M. the Director of Nursing (DON) said she would expect nurses to accurately document which arm was used for blood pressure readings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 225529