Carecore at Gaymont

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure activities of daily living (ADLs) were performed timely for residents who required assistance, This affected four (#24, #25, #26, and #53) of four residents reviewed for ADLs. The facility census was 73.

Inspectors wroteBased on observation, record review, interview, and review of the facility policy revealed the facility failed to ensure Resident #1 and #47's open areas were addressed timely and failed to ensure Resident #12 and #58's physician orders were followed as prescribed. This affected two (Resident #1 and #47) of three residents reviewed for open areas and affected two (Resident #12 and #58) of five residents reviewed for following physician orders. The facility census was 73.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, review of manufacturer's instructions, review of product label, and policy review, the facility failed to ensure Med Pass (a concentrated, high-calorie, and high-protein liquid nutrition drink given during routine medication administration times) was not left at bedside and was properly stored. This had the potential to affect 17 (#6, #21, #25, #28, #30, #32, #38, #42, #45, #48, #51, #58, #64, #68, #69, #71, #72) residents identified by the facility as having orders for Med Pass. Additionally, the facility failed to ensure medications were not left at the bedside when administered to three residents (#1, #38, and #56). Furthermore, the facility failed to ensure the medication room was locked, and medications were not accessible to residents. The facility census was 73.

Inspectors wroteBased on observation, interview, and review of the facility policy revealed the facility failed to assure hair nets were properly worn by staff while working in the kitchen and failed to assure kitchen equipment was maintained in a clean manner. This had the potential to affect all residents residing at the facility except one resident, Resident #9, identified by the facility not receiving meals from the kitchen. The facility census was 73.

Inspectors wroteBased on record review, staff interview and family interview, and review of the facility policy, the facility failed to timely notify the primary/emergency contact of a resident's significant change in condition. This affected one (#91) of three residents reviewed for notification. The facility census was 73.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and policy review, the facility failed to ensure a safe, clean, comfortable, homelike environment. This affected three (#18, #44, and #47) of five residents reviewed for a safe, clean, comfortable, homelike environment. The facility census was 73.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and review of the facility policy the facility failed to assure pain medications were reordered timely and available for administration when requested. This affected one (#38) resident of three resident reviewed for pain. The facility census was 73.

Inspectors wroteBased on observations, medical record review, resident interview, staff interviews, and policy review, the facility failed to develop and implement a comprehensive, effective, and individualized nutritional program to ensure nutritional recommendations were addressed timely, nutritional interventions were implemented as recommended, and/or to recognize and address severe resident weight loss. Actual Harm occurred when Resident #122, who was admitted with an unplanned significant weight loss and tested positive for COVID -19 two days after admission, experienced a severe weight loss of 17.6% pounds, within 21 days of admission. Upon admission on [DATE], Resident #122 weighed 75 pounds and on 04/25/24 Resident #122 weighed 61.8 pounds. [...]

Inspectors wroteBased on review of the medical record, observation, resident interview, staff interview, and policy review, the facility failed to ensure resident rooms were timely cleaned and maintained in good repair. This affected four (#11, #53, #38, #21) of six residents reviewed for environment. The facility census was 70.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and policy review, the facility failed to ensure call lights were in reach of residents. This affected two (#51 and #122) of 19 residents reviewed for call lights. The facility census was 70.

Inspectors wroteBased on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure a resident's preference for showers was honored. This affected one (#4) of one resident reviewed for choices. The facility census was 70.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident's code status was consistent throughout the medical record. This affected one (#53) of one resident reviewed for advanced directives. The facility census was 70.

Inspectors wroteBased on observations, medical record review, staff interview, and policy review, the facility failed to ensure a resident with a pressure ulcer was provided pressure ulcer prevention interventions. This affected one (#122) of two resident identified by the facility with pressure ulcers. The facility census was 70.

Inspectors wroteBased on observation, staff and resident interview, record review, and policy review, the facility failed to ensure residents receiving supplemental oxygen had complete physician's orders for oxygen administration. This affected three (#45, #62, and #224) of three residents reviewed for respiratory care. The facility identified 13 residents who required the use of supplemental oxygen. The facility census was 70.

Inspectors wroteBased on staff interview, record review, and policy review, the facility failed to comply with the requirements for binding arbitration agreements of allowing up to 30 days to rescind the agreement and allow for a neutral arbitrator according to policy This affected three (#04, #37, and #52) of three residents reviewed for binding arbitration. The facility identified ten residents who had signed the facility's binding arbitration agreement. The facility census was 70.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure resident room ceilings were maintained in good repair. This affected five residents (#25, #45, #50, #59, #72) of six residents reviewed for the physical environment. The facility census was 71.

Inspectors wroteBased on observation, staff interview, and review of the facility's recipes, the facility failed to ensure food was prepared in a way that was flavorful and palatable. This had the potential to affect all 71 residents who received food from the kitchen.

Inspectors wroteBased on observations, policy review, and staff interviews, the facility failed to store food and kitchen equipment in accordance with professional standards for food service safety. This had the potential to affect all 71 residents who receive food from the kitchen.

Inspectors wroteBased on record review, observation, staff interview and review of the facility's policy, the facility failed to ensure a medication cart and treatment cart were locked. This had the potential to affect nine residents (#7, #17, #19, #23, #37, #38, #43, #63, and #217) residing in the secured unit who were independently mobile with cognitive impairment. The facility census was 71.

Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to ensure call lights were within reach and accessible. This affected one (Resident #318) of 31 residents reviewed for call light placement. The facility census was 71.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure Residents #169's wanderguard (device used to alert staff of resident movement and potential exit seeking behaviors) was in place for a valid medically necessary reason. This affected one (Resident #169) of one residents reviewed for restraints. The facility identified there were zero residents with physical restraints. The facility census was 71.

Inspectors wroteBased on observation, record review, policy review, and staff interviews, the facility failed to ensure residents request and preferences for hydration were honored. This affected one (Resident #22) of one resident reviewed for preferences honored. The facility census was 71.

Inspectors wroteBased on record review, staff interview, and review of the facility's policy, the facility failed to ensure residents were provided bed hold notices when transferred to the hospital. This affected two (#66 and #67) of four residents reviewed for hospitalization. The facility census was 71.

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to ensure food temperature was obtained before serving from the steam table and failed to ensure staff wore proper hair covers while serving food from the dementia unit. This had the potential to affect twenty (Resident #14, #23, #27, #28, #29, #30, #36, #41, #49, #60, #61, #65, #67, #79, #81, #88, #91, #242, #244, #292), residents identified by the facility that ate in the Maple and dementia unit dining rooms. The facility census was 87. Findings Include: 1. Observation on 10/01/19 at 12:02 P.M., of the dining in the dementia unit revealed Activity Director (AD) #159 walking behind the steam table getting a cup and accessing the refrigerator without a hair net. [...]

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure ongoing individualized activities were provided. This deficient practice had the potential to affect one of 24 (Resident #41) observed for activity involvement. Facility census 87.

Inspectors wroteBased on review of physician orders, review of wound care notes, resident interview, staff interviews, and policy review, the facility failed to clarify physician orders for a pressure relieving cushion and wound treatments. This affected one (#71) of three residents reviewed for pressure ulcers. The facility identified five residents with pressure ulcers. The facility census was 87.

Inspectors wroteBased on observation, medical record review, staff interview, facility urinary incontinence protocol, the facility failed to ensure urinary continence was promoted. This affected one resident (#2) reviewed for urinary incontinence. Facility census 87.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure appropriate technique for tracheostomy care and failed to wear a face mask and eyewear when performing tracheostomy care. This affected one (Resident #89) resident of one reviewed for tracheostomy care. The facility census was 87. Findings Include: Review of Resident #85's medical record revealed an admission date of 08/18/15 with diagnoses including encounter for attention to tracheostomy, chronic respiratory failure, anoxic brain damage and disturbances of salivary secretions. Review of the care plan revealed the resident had a tracheostomy related to respiratory failure and vegetative state following an accident. Interventions included to use universal precautions per facility policy and provide trach care every shift and as needed. [...]