MARY GRACE CARE HOME, LLC

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.

Findings include:

1. A review of Department documentation revealed the facility was authorized to provide directed care services.

2. During an environmental inspection of the facility, the Compliance Officer observed a device above the door leading to the facility's backyard. However, upon opening the uncontrolled door, the device failed to make any sound to alert employees of egress from the facility.

3. In an interview, E4 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on record review, documentation review and interview, for one of two residents reviewed, who received a controlled substance, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility.

Findings include:

1. A review of R2's medical record revealed medication orders that included the following prescribed medications:
-Oxycodone 20 Mg Oral Concentrate, every 1 hour as needed- take only as needed
-Morphine 5mg, every 4 hrs as needed
-Fentanyl 25 Mcg/hr Transdermal Patch, every 72 hours

2. A review of the facility's policies and procedures revealed a policy titled "Storing, Dispensing, and Disposing Controlled Substances." The policy stated, "...the receipt, administration and disposal of controlled substances or drugs must be recorded in a register. The register must include the balance remaining for each product...2. When assisted a resident in taking a controlled medication, a staff member should a) turn to the Narcotic Inventory Sheet...write in the date, time and signature...b) count the number of tablets/capsules available and enter the number...on the form..."

3. A review of the facility's policies and procedures revealed a policy titled "Opioid Administration and Assistance in the Self-Administration of Opioids Policy and Procedures." The policy stated..."an identification of the patient's need for the opioid before the opioid was administered...was provided...the effect of the opioid administered...for a prescribed opioid was provided...6. patients under hospice care...caregiver must identify the patient's need for the opioid before the opioid administration...must be documented in the Controlled Substance Administration Record and Inventory Flowsheet...9. Resident's relief of pain will be assessed by the trained caregiver between 30 minutes to one hour after administration and response must be documented in the Controlled Substance Administration Record and Inventory Flowsheet."

4. A review of R2's medical record did not contain a document titled "Narcotic Inventory Sheet" or a document titled "Controlled Substance Administration Record and Inventory Flowsheet."

5. In an interview, E4 acknowledged the required documentation was not available for review or included in R2's medical record per the facility's policy and procedures.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a health and safety risk to residents and employees if the disaster plan was not up-to-date to adequately meet the needs of the residents during a disaster.

Findings include:

1. In documentation review, the facility's disaster plan did not indicate the plan was reviewed at least once every 12 months, as required.

2. During an interview, E4 acknowledged the facility did not have documentation the disaster plan was reviewed at least once very 12 months.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. During the environmental tour of the facility, the Compliance Officer observed an unlocked cabinet under R2's bathroom sink. The unlocked cabinet contained Comet and Shout spray.

2. During the environmental tour of the facility, the Compliance Officer observed an unlocked cabinet under the kitchen sink. The unlocked cabinet contained Lysol disinfectant spray and Endust Multi-Surface Dusting Cleaning Spray.

3. In an interview, E2 and E4 acknowledged toxic materials were not stored in a locked area and inaccessible to residents.

Based on record review and interview, the manager failed to ensure one of one resident record sampled contained a written service plan that included the level of service the resident was expected to receive. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident.

Findings include:

1. A review of R1's medical record revealed a written service plan dated November 11, 2023. However, the service plan did not include documentation of the level of service the resident was expected to receive.

2. In an interview, E1 reported R1 received personal care services. E1 acknowledged the service plan did not include the level of service R1 was expected to receive.

Based on record review, documentation review, and interview, the manager failed to ensure when a resident had a accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or assistant caregiver immediately notified the resident's emergency contact. The deficient practice posed a risk to the health and safety of R1 if R1's emergency contact was required to make medical decisions and/or coordinate care.

Findings include:

1. A review of R1's medical record revealed an incident report dated December 17, 2023 at 8:15 AM. The incident report indicated R1 had a fall which required E3 and E4 to clean the resulting wound on the back of R1's head, change R1's clothing, and call R1's hospice agency to send a nurse to assess R1's condition.

2. According to the incident report, O1 determined R1 did not require any additional medical services. O1 left the facility at approximately 9:30 AM.

3. A review of Department documentation reported R1's emergency contact was not contacted regarding R1's fall.

4. In an interview, O2 reported R1's emergency contact was not notified of R1's fall.

5. In an interview, E1 acknowledged R1's emergency contact was not notified of R1's fall and treatment. E1 reported the facility assumed the hospice agency would notify the emergency contact. However, the hospice agency did not notify R1's emergency contact.