Life Care Center Of The South Shore

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement their abuse policy when Resident (#42) was involved in a verbal resident-to-resident altercation with Resident #83. Specifically, the facility failed to ensure facility staff who were aware of the incident reported the altercation to leadership immediately, but not later than 2 hours after the altercation, to allow for reporting, investigating, and implementing measures to prevent potential future altercations. Findings include:Review of the facility's policy titled Abuse - Identification of Types, reviewed 4/1/26, indicated, but was not limited to, the following:-Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.-Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.-Verbal abuse may be considered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, for one Resident (#42), of 22 sampled residents, the facility failed to ensure an allegation of abuse was reported timely to the state agency as required.Findings include:Review of the facility's policy titled Abuse - Identification of Types, reviewed 4/1/26, indicated, but was not limited to, the following:-Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.-Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.-Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include, but are not limited to:i. Harassing a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#2), in a total sample of 22 residents, received assistance with activities of daily living (ADLs). Specifically, Resident #2 was not provided set-up and supervision with eating as the assessments indicated. Findings include:Resident #2 was admitted to the facility in February 2026 with diagnoses of Lewy Body Dementia (a brain disorder that can lead to problems with thinking, movement, behavior, and mood) and essential tremors. Review of the Minimum Data Set assessment, dated 3/16/26, indicated Resident #2 scored 6 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severely impaired cognition and indicated Resident #2 needed supervision or touching assist with eating. Review of the care plans indicated Resident #2 required set-up/supervision assistance by one staff with eating (dated 4/9/26). Review of the assessment titled Interdisciplinary Team (IDT): Decision to Support Section GG, dated 3/13/26, indicated Resident #2 needed supervision or touching…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed:1. To ensure two of two medication carts on the secured unit were locked when not in direct supervision of the licensed nurse; and2. For Resident #85, to ensure the Resident's lactase enzyme (medication that helps break down lactose, preventing symptoms like gas, bloating, and diarrhea when consuming dairy), albuterol inhaler (a medication that relaxes muscles in the airways, increasing airflow to the lungs, commonly used to treat conditions like asthma and chronic obstructive pulmonary disease), and analgesic balm (topical pain relief medication) were stored securely. Findings include:Review of the facility's policy titled Storage and Expiration Dating of Medications and Biologicals, revised 06/30/25, indicated but was not limited to the following: -Facility should ensure all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure his/her Minimum Data Set (MDS) Assessment accurately reflected his/her behaviors of wandering and repeated requests to go home, which contributed to a delay in developing a plan of care and implementing interventions to address these behaviors. Findings include: Review of the Facility Policy titled, Resident Assessment Instrument (RAI) and Care Plan Development, dated as last revised 08/22/2023, indicated the following; -The MDS Assessment uses patient observation, staff, family, and patient interviews to form the foundation of the comprehensive assessment; -The Care Area Triggers are derived from the information coded on the MDS that identify patient who have or at risk for developing specific functional problems that require further assessment; and -The information identified using the MDS and Care Area Assessment process is used to develop an individualized person-centered care plan that includes the patient's voice, the patients' goals while residing in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who upon admission wandered, verbalized to staff that he/she wanted to go home and had physician's orders for psychotropic medication for anxiety and depression, the Facility failed to ensure that upon admission, nursing developed and implemented a baseline care plan with interventions, treatments, goals, and outcomes that addressed the residents overall immediate care needs. Findings include: Review of the Facility Policy titled, Baseline Care Plan, dated as last revised 08/11/23, indicated that a baseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provided effective and person-centered care of the resident that meet professional standards of care. Resident #1 was admitted to the Facility in March 2024, diagnoses include neurocognitive disorder with Lewy Body Dementia (problems with thinking, unpredictable changes in attention and alertness), atrial fibrillation (irregular, often rapid heart rate that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who upon admission exhibited wandering behavior and verbalized to staff that he/she wanted to go home, the Facility failed to ensure that the Interdisciplinary Team developed and implemented a person-centered comprehensive care plan with interventions, treatments, goals, and outcomes that addressed the resident's risk for wandering and/or elopement. Findings include: Based on the Facility Policy titled Comprehensive Care Plans and Conferences, dated as last revised 08/22/2023, indicated that the facility is required to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a residents medical nursing, and mental psychosocial needs that are identified in the comprehensive assessment. The Policy also indicated the following; -The Comprehensive Care Plan cannot be completed until the MDS, the Care Area Triggers are addressed through the CAA Assessment Process; and -Identify and collect information that is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who upon admission exhibited wandering behaviors and had verbalized to staff that he/she wanted to go home, the Facility failed to ensure he/she was provided an adequate level of staff supervision to prevent an incident of elopement, when on 04/01/24 at approximately 3:30 P.M., despite his/her photograph being placed at the reception desk alerting staff to the fact he/she was identified as an elopement risk, he/she successfully eloped from the facility when the receptionist on duty let him/her out of the facility. Resident #1 was found at the home of a family member in another town. Findings include: Review of the Facility Policy, titled Unsafe Wandering and Elopement Prevention, dated as last revised 08/10/21, indicated the Facility would promote safety and reduce unsafe wandering and elopements by proactively identifying, care planning and monitoring of Resident wandering and elopement indicators. The Policy further indicated the following; -Residents will be assessed for unsafe wandering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, the facility failed to designate a person who met the minimum qualifications to serve as the Director of Food and Nutrition Services. Findings include: During an interview with the Dietitian and the Food Service Manager (FSM) on 1/29/24 at 10:40 A.M., the Dietitian said she is employed 32 hours per week and is in the building four days a week. The FSM said he has been employed since September 2023 and currently is not certified as a Food Service Director. He said he is enrolled in an online class starting in February. During an interview on 1/31/24 at 1:00 P.M., the Dietitian said most of the time when she is in the building, she is in meetings. She said she has tried to help in the kitchen and provide some education and support to the Food Service Manager, but it has been tough. During an interview on 1/31/24 at 2:15 P.M., the Administrator said he understands the FSM does not currently meet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure milk cartons stored in the milk chest and served to the residents were not expired; 2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination. In addition, ensure the use of gloves was limited to a single use task; 3. Ensure the floor in front of the food service line was maintained in a sanitary condition when food service operation was occurring; 4. Service the main kitchen ice machine per the facility policy; 5. Ensure food items designated as emergency supply were stored in a clean environment and were not expired; and 6. Ensure the clean side of the dishwasher in the dish room was maintained in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, the facility failed to maintain and consistently implement an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for one Resident (#7), out of a total sample of 18 residents. Specifically, the facility failed to ensure Enhanced Barrier Precautions (EBP), including a gown, was consistently implemented during care. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions, revised 6/12/23, included but was not limited to: -The facility may use Enhanced Barrier Precautions (EBP) as an additional MDRO (multi drug resistant organism) mitigation strategy for residents that meet the following criteria, during high-contact resident care activities. -Indwelling medical devices (e.g., central line, urinary catheter, feeding tube, trach, ventilator) regardless of MDRO colonization status. -Post clear signage on the door or wall outside of the resident room indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.