Life Care Center Of Gray

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, facility investigation review, and interviews the facility failed to maintain or enhance 1 resident's (Resident #4's) dignity and respect when 1 Certified Nursing Assistant (CNA) cursed in front of the resident while providing care of 11 residents observed for resident rights. The findings include: Review of the facility's policy titled, Resident Rights, dated 9/25/2023, revealed .Resident Rights .The resident has a right to a dignified existence . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Dementia with Anxiety, Abnormal Involuntary Movements, Depressive Disorder, and History of Falling. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 1 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of a comprehensive care plan for Resident #4 revised 6/11/2024, revealed…

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 review of facility policy review, medical record review, facility documentation review, witness statement review, observation, and interviews, the facility failed to implement a behavioral and wandering care plan. The facility's failure to implement a behavioral and wandering care plan resulted in 1 of 6 (Resident #1) sampled residents being secluded in the dining/day room area of the secured unit for an unspecified amount of time. The findings include: Review of the facility's undated policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, showed .All residents have the right to be free from .unreasonable confinement .It is the policy and practice of [Named Facility] that all residents will be protected from abuse .Abuse means .unreasonable confinement .Definitions .the willful .unreasonable confinement .Involuntary Seclusion Separation of a resident from other residents .or confinement .with or (without roommates) against the resident's will or of the responsible party . Review…

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 facility policy review, observations, and interview the facility failed to maintain sanitary kitchen equipment, failed to maintain a sanitary kitchen environment as evidenced by undated and unsealed food observed in 1 of 1 walk-in freezer and 1 of 1 kitchen preparation (prep) table, failed to ensure 1 of 4 kitchen staff wore protective beard coverings while preparing food, which had the potential to affect 70 of 70 residents. The findings include: Review of the facility's policy titled, Food Procurement, Diets, Menus, and Production, dated 4/26/2023, showed .Food safety requirements the facility must .Store, prepare, distribute and serve food in accordance with professional standards for food service safety . Review of the facility's policy titled, Associate Conduct and Dress Code, dated 3/28/2023, showed .The facility will ensure all food service associates adhere to the company's established code of conduct and dress code .Store, prepare, distribute and serve food in accordance with professional standards for food safety .Dietary staff must wear hair restraints .beard…

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 facility policy review, observations, and interviews, the facility failed to maintain a safe, comfortable, and homelike environment for 4 residents (Residents #21, #38, #56 and #270) of 28 residents reviewed on the secure unit. The findings include: Review of the facility policy titled, Resident Belongings and Home Like Environment, reviewed 7/17/2023, showed .The facility will provide a safe, clean, comfortable, and homelike environment .The resident has a right to a clean, comfortable and homelike environment .ENVIRONMENT .Refers to any environment in the facility that is frequented by residents, including .resident's rooms, bathrooms .It is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs . Review of the facility policy titled, Residents Rights, reviewed 10/6/2022, showed .The resident has a right to a safe, clean, comfortable and homelike environment . Resident #21 was admitted to the facility on [DATE] with diagnoses including…

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 facility policy review, medical record review and interview, the facility failed to make a referral, to the state-designated authority, for a Level II Pre-admission Screening and Resident Review (PASARR) after a newly identified mental health disorder was diagnosed for 1 resident (Resident #59) of 24 residents reviewed for PASARR. The findings include: Review of the facility policy titled, Pre-admission Screening and Resident Review (PASARR), revised 10/6/2022, showed .Referring all level II residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment .A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in mental or physical condition of a resident who has a mental illness or intellectual disability for resident review . Review of Resident #59's Level I PASARR dated…

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 facility policy review, medical record review, and interview, the facility failed to ensure informed consent for use of Psychotropic medication was obtained prior to administration for 1 resident (Resident #120) of 6 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Psychotropic Medication Informed Consent Policy, dated 10/4/2022, showed .The facility will obtain consent or refusal to the use of Psychotropic Medications. This documentation will reflect the intended or actual benefit is understood by the resident and, if appropriate, his/her family and/or representative . Resident #120 was admitted to the facility on [DATE] with diagnoses including Hypertension, Type 2 Diabetes Mellitus, Heart Disease, and History of Falling. Review of a Physician's order dated 5/5/2023, showed an order for .Haldol [anti-psychotic medication] 5 mg [milligrams] .q [every] 8 hours as needed for anxiety . Continued review of the Medication Administration Record for…

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 facility policy review, observation and interview, the facility failed to ensure garbage and refuse was properly contained in 2 of 3 dumpsters observed. The findings include: Review of the facility's policy titled, Disposal of Garbage and Refuse, dated 9/8/2022, showed .Facility will have a process in place to properly dispose of garbage and refuse .Garbage and refuge containers are in good condition . During an observation and interview on 9/17/2023 at 11:15 AM, the garbage storage area showed 2 dumpsters had a quarter-sized opening, at the drain plug site, in the bottom corner of both dumpsters. The drain plugs were not present and had not been replaced. The quarter-sized opening allows for waste materials to leak out and rodents or pests' entry. The CDM confirmed the dumpsters did not have drain plugs that had caused a quarter-sized opening to exist. During an interview on 9/17/2023 at 10:29 AM, the General Supervisor of Solid Waste (GSSW) stated he was over the facility's dumpster and waste service and had not been contacted by the facility to apply new drain plugs to 2…

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 facility policy review, medical record review, observation and interview the facility failed to maintain infection control during medication administration for 1 resident (Resident #23) of 3 residents reviewed for medication administration. The findings include: Review of the facility policy titled, Preparing for Medication Administration, undated, showed .Hand Hygiene .During the medication pass, perform hand hygiene and use gloves . Resident #23 was admitted to the facility on [DATE] with diagnoses including Fracture of Right Arm, Fracture of Right Humerus, Type 2 Diabetes Mellitus, and Overactive Bladder. Review of a physician's order dated 6/22/2023, showed Resident #23 had an order for .oxybutynin [medication for overactive bladder] 5 mg [milligrams] .give 1 tablet by mouth one time a day . During an observation and interview on 9/18/2023 at 7:43 AM, showed Licensed Practical Nurse (LPN) #1 preparing medications for administration for Resident #23. LPN #1 noted the oxybutynin 5 mg was not 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview the facility failed to ensure the medication pass error rate was below 5% effecting 4 residents (#3, #66, #131, and #132) of 9 residents observed during medication administration. The findings include: Review of facility policy, General Dose Preparation and Medication Administration, revealed .Facility staff should verify that the medication name and dose are correct . Medical record review revealed resident #3 was admitted to the facility on [DATE] with diagnoses including Dementia, Peripheral Vascular Disease, and Heart Disease. Medical record review of the current Physician recapitulation orders for October 2018, revealed .vitamin B12 (type of vitamin) 500 mcg (micrograms) . Observation of Licensed Practical Nurse (LPN) #1 on 10/31/18 at 7:33 AM, on the 300 hall, revealed the LPN obtained a stock bottle of vitamin B12 1000 mcg and administered the B12 to resident #3. Interview with the LPN on 10/31/18 at 8:20 AM, on the 300 hall,…

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 medical record review and interview the facility failed to notify the state mental health authority of a new serious mental illness diagnosis (SMI) for 1 resident (#35) of 34 residents reviewed. The findings include: Medical record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Dementia, Unspecified Psychosis, and Anxiety Disorder. Medical record review of .Demographics .Diagnosis . form revealed .Bipolar disorder, current episode mixed, severe, with psychotic features .Onset 8/09/18 . Further medical record review revealed no documentation of notification of the state mental health authority of the new diagnosis of Bipolar Disorder. Interview with the Business Office Manager on 10/31/18 at 8:48 AM, in the Business Office, confirmed the facility failed to notify the state mental health authority of a SMI diagnosis for Resident #35.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, medical record review, and interview, the facility failed to monitor behaviors for 1 resident (#61) of 5 residents reviewed for dementia of 26 residents sampled. The findings include: Review of facility policy Behavioral Health Management revised 10/3/17 revealed .To promote resident safety, attain highest practicable mental / psychosocial well-being and reduce behavior related events . Medical record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Anxiety Disorder, Psychosis and Depression. Medical record review of the care plan dated 6/18/18 revealed .Risk for decline in mood and or behavior .monitor behavior . Medical record review of Resident #61's behavior/intervention monthly flow record dated 8/1/18 through 8/31/18 revealed the resident had occasional episodes of continuous anxiety with worsened outcomes after redirection and 1:1 supervision. Medical record review of a psychiatric evaluation dated…

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.