A Grace Sub Acute & Skilled Care

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of one of three sampled residents (Resident 1) when medications were not available to be administered as ordered. This failure had the potential to compromise the resident's health and safety.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure professional standards of practice were followed for five out of 22 sampled residents (Residents 25, 35, 75, 93, and 98) when: For Residents 25, 35, 93, and 98, there were incomplete physicians orders, which had the potential for unsafe implementation of the orders and untimely treatment or intervention residents' medical conditions. For Resident 75, the staff took the blood pressure (BP) on the same arm where the resident has the AV fistula (arteriovenous fistula, connection that's made between an artery and a vein for dialysis access), did not monitor her intake and output (the measurement of the fluids that enter the body and the fluids that leave the body). The failures had the potential to cause injury and unmonitored medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer and/or attempt alternatives prior to the use of side rails (or bed rails, adjustable rigid bars attached to the side of a bed [examples include safety rails, grab bars, and assist bars]) for 18 of 22 sampled residents (Residents 66, 38, 75, 77, 13, 4, 9, 5, 73, 57, 29, 54, 98, 6, 99, 28, 82, and 16) and 77 nonsampled residents. This failure had the potential to place the residents at risk of entrapment and serious injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) and document medication administration as in accordance with the facility policy and procedures (P&P) for 3 out of 5 residents (Residents 35, 39, and 85). The failure had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally).

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. Undated food items, food past their used by date, bananas with black spots, partially soft and ruined tomatoes, dry green onion were found in the refrigerator and on the shelves in the kitchen; 2. A tube of Auto-Chlor test strips (used to test the chemical concentration of cleaning solutions to ensure that sanitizers are used appropriately in dishwashers, sinks, and buckets) was expired; and 3. Dietary supervisor (DS) did not sanitize the contaminated thermometer before checking the temperature of the lemonade. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 44 residents eating at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection prevention techniques were followed when: 1. two oxygen concentrators had dirty filters, 2. a nurse did not wear appropriate personal protective equipment (PPE), two times during medications pass, for one of six residents who was on enhanced barrier precautions (a set of infection control measures that use gowns and gloves during high-contact care activities to reduce the spread of multidrug-resistant organisms), and 3. during personal care, the urine collection bag for one of 17 residents with a urinary catheter (a tube which is used to allow urine to drain if you have an obstruction in the tube that carries urine out of your bladder), was placed on the mattress of the bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accommodation of needs for one of 22 residents (Resident 81) when Resident 81 did not have the appropriate staff call device (call button) that she would be able to use if she needed to call for assistance. This failure had the potential to result in the resident not getting assistance timely and delay necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for two of 22 sampled Residents (Resident 66 and Resident 25). This failure had the potential for the residents and/or responsible party (RP) to be unaware of the plan of care.

Inspectors wroteBased on interview and record review, the consultant pharmacist (CP) failed to identify and report irregularities to the facility during the monthly regimen review (MRR) for two out of 20 sampled residents (Residents 5 and 93). The failure resulted in an unsafe order without being clarified for Resident 93, and Resident 5 not receiving the medication in accordance with the manufacturer's specifications to optimize drug therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of 22 sampled residents (Residents 35 and 98) were free from unnecessary medications when Resident 35 received warfarin (a blood thinner to prevent blood clots) for a wrong indication; and Resident 98's lidocaine patch (a topical medication applied to the skin for pain) was not administered in accordance with the manufacturer's specifications. This deficient practice resulted inadequate indication for medication use; and the potential for adverse effects of medication.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 5.56% when two medication errors occurred out of 36 opportunities during the medication administration for 2 out of 6 residents (Residents 67 and 93). The failures resulted in the nursing staff not following the facility's policy and procedures (P&P) and had the potential for the residents not receiving full therapeutic effects or complications of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meals with food items according to preferences and dislikes for two of 44 residents (55 and 67). This failure had the potential to result in meal dissatisfaction, decreased intake, and leading to compromised nutritional and medical status for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 27 initial pool residents (Resident 1) had access to a staff call device (call button), in case of needing help or for an emergency. This failure had the potential of Resident 1 becoming seriously harmed or even lead to death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, functional, and sanitary environment for one of 22 sampled residents (Resident 28) due to cracked walls near Resident 28's bathroom door and at the bottom left side of the toilet in the bathroom. This deficient practice had the potential to adversely affect the health and safety of residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete a Morse Fall Scale (an assessment used to determine a resident's risk for falls) after a fall for one of three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to identify fall risk factors and implement interventions accordingly.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Fall Morse Scale was completed accurately for one of two sampled residents (Resident 1). The failure to accurately assess residents ' fall risk has the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions for falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. A physician order for the wearing of a hand splint was not followed; 2. A physician order for the wearing of a knee brace was not followed; 3. RNA (Restorative Nursing Assistant) services were not provided as ordered; These failures resulted in Resident 1 not receiving proper treatment and had the potential to compromise Resident 1's health and well-being.

Inspectors wroteDuring an observation on 5/9/22 at 12:44 p.m., CNAs were seen passing out the lunchtime meal trays to the residents. There were two food carts parked in the hallway of station three and station four which contained the lunch trays of the residents. Two LNs were seen in the hallways of station three and four, standing by their medication carts, and were not participating in the passing of the lunch trays to the residents. During an interview with licensed vocational nurse D (LVN D) on 5/9/22 at 12:44 p.m., he was asked if he checked the contents of the meal trays before the CNAs distributed lunch to the residents on station three and station four. LVN D stated No I did not, I do it if I have time. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when: 1. Random controlled medication use audit for three of four sampled residents' (Residents 23, 48, and 71) as-needed controlled medications did not reconcile. The medications were signed out of the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were given to the residents. 2. Three of five controlled drug sign-in/sign out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the incoming and outgoing nurse during a shift change) were missing signatures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 15.63% when five medication errors occurred out of 32 opportunities during medication administration for four of five sampled residents (Residents 42, 53, 64, and 72). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications and possible side effects for residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow proper sanitation and food handling practices when: 1. There were uncovered food items in the facility's kitchen freezer; 2. There was one unlabeled and undated pitcher of pink liquid in the reach-in refrigerator; and 3. Food service equipment was stored wet. These failures had the potential to cause food contamination and food-borne illness to 47 of 47 residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Licensed vocational nurse D (LVN D) did not perform hand hygiene in between tasks; 2. Face shield unattended on top of a cart parked in the hallway; 3. Certified nursing assistant K (CNA K) did not tie her isolation gown before entering an isolation room; 4. The restorative nursing assistant (RNA) did not follow the sequence in donning personal protective equipment (PPE). 5. Resident 25 did not have a daily Covid-19 screening monitoring; 6. LVN A did not perform hand hygiene in between changing gloves; 7. Irrigation syringe was hanging on the gastric tube (GT) machine. These failures could result in the spread of infection and cross-contamination that could affect the 87 residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention in order to obtain agreement or permission for care, treatment, or services) for an increased dose of an antipsychotic medication (a type of psychotropic medication to manage psychosis including delusions, hallucinations, paranoia, or disordered thought) for one of 23 sampled residents (Resident 48). This failure had the potential to compromise the right of the residents or responsible parties (RPs, persons designated to make decisions of behalf of the residents) to be fully informed regarding care and treatment to make health care decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to address resident's needs for one of three sampled residents (Resident 74) when Resident 74 was not able to reach for her call light. This failure had the potential for residents' needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a residents' personal health information for one of three computer monitors. This failure had the potential for the public to see or access resident's personal medical and demographic information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to prevent contracture (condition leading to deformity) for two of nine sampled residents (Resident 77 and Resident 28) when: 1. Resident 77's lower extremities (legs and feet) did not have heel protectors (device to prevent deformity) applied on bilateral feet. 2. Resident 28 did not have a splint (device used to protect deformity) applied on his left arm as ordered. These failures had the potential to cause or worsen bone deformities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely assessment and intervention for pain for one of two sampled residents (Resident 68). This failure had the potential for increased pain and discomfort for Resident 68.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for one of one resident (Resident 23) when Resident 23's dialysis site dressing was not removed as ordered. This deficient practice had the potential for the resident to be inadequately assessed and be at risk for complications.

Inspectors wroteBased on observation, interview and record review, the consultant pharmacist (CP) failed to identify and report the irregular medication orders for two of seven sampled residents (Residents 64 and 84) in the monthly Medication Regimen Review (MRR). This failure resulted in medications not given in accordance with accepted standards of practice and had the potential for not meeting the residents' therapeutic needs or excessive use of medications for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 23 sampled residents (Residents 48 and 13) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. The facility increased Resident 48's Seroquel (an antipsychotic medication) for bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) without adequate indication and documentation, and did not monitor the resident's lipid panel (a test that measures the amount of certain fat molecules called lipids in the blood) annually while the resident was on two antipsychotic medications. 2. For Resident 13, there was no specific behavior for the use of Seroquel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Temperature monitoring was not consistently documented twice daily on the temperature log sheet, in May 2022, for one of two medication refrigerators; 2. Two insulin (medication to treat high blood sugar) pens had the pharmacy label on the caps instead of the body of the pens; 3. One opened tuberculin purified protein derivative (PPD, a solution used for tuberculin skin test) multi dose vial, one insulin pen, and an opened insulin vial were without the open date or discard date, to make sure they were not used beyond the discard date; 4. Two residents' expired medications were not removed from stock; 5. One unopened insulin vial was not labeled after removing from the refrigerator; 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist and provide emergency dental care for one of two sampled residents (Resident 68). This failure had the potential for Resident 68 to suffer pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure proper infection control practices was followed when: 1. Resident 382's undated used gastrostomy (GT, a surgical opening into the stomach for administration of nutrition and medications) syringe, opened unlabeled one gallon of distilled water were in the resident's room. 2. Resident 90 outdated nebulizer tubing was left on top of the machine. 3. Resident 131's suction machine (a device act or process of sucking) tubing was hanging and touching the floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a resident's privacy for two of 25 sampled residents (Residents 382 and 76) when their body was exposed from the waist down and could be viewed outside from the hallway. This failure had the potential to affect Residents 382 and 76's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent for psychotropic medication (medication capable of affecting the mind, emotions, and behavior) for one of five sampled residents (Resident 36). This failure resulted in Resident 36 not being aware of the risks and benefits of taking psychotropic medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify all pertinent officials, in a timely manner, following an allegation of abuse for one of two residents (Resident 103) when Resident 103 had notified a staff member of her allegation. This failure had the potential to delay identification and implementation of appropriate corrective action and put the residents at risk for abuse.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Long Term Care Ombudsman (Ombudsman, an advocate for residents in the nursing homes) was notified in writing of a transfer for four of four residents (Residents 43, 78, 95 and 106). This failure had the potential of not providing the resident and/or their responsible party (RP, a person who is accountable in making decision in behalf of the resident) with access to an advocate who could inform them of their rights and from being inappropriately transferred.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the minimum data set (MDS, an assessment tool) for seven of 25 residents (Residents 8, 61, 104,35,45,125 and 108) when their MDS did not reflect the current status of the residents. This failure had the potential to affect inappropriate care planning and intervention.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an individualized person-centered comprehensive care plan for four of 25 residents (Residents 35, 43, 32 and 94) when: 1. Resident 35's hand roll intervention was not implemented; 2. Resident 43's care plan was not revised; 3. Resident 32's care plan was not developed for enoxaparin sodium (anticoagulant medication); and 4. Resident 94's care plan was not developed for zolpidem tartrate (sedative-hypnotic medication) and enoxaparin sodium. These deficient practices had the potential for the resident's needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate treatment and services were provided for three of seven residents (Residents 35, 36, 43, and 107) when the restorative nursing assistant (RNA, program that helps residents to gain an improved quality of life by increasing their level of strength and mobility) program was not implemented. This deficient practice had the potential to result in residents' decline in range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube, a tube inserted through abdomen that delivers nutrition and hydration directly to the stomach) was implemented for one of four sampled residents with G-tube (Resident 73). The facility failed to ensure a physician order was followed when the gastrostomy tube was not available for replacement when obstructed. This failure had the potential to delay the nutritional needs and compromise the health of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five residents (56 and 125) with behavior problems were adequately monitored. For Residents 56 and 125, the facility did not follow-up on psychiatric services (referral). This failure could potentially affect the residents' highest physical, mental and psychosocial well- being.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate accounting of controlled substance (CS) medications (medications with a high risk for abuse and addiction) when random CS medication audits did not reconcile for seven of 19 residents (Residents 36, 37, 41, 59, 60, 88 and 382). This failure had the potential to result in the abuse or the misuse of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents were free from unnecessary drugs for four of four sampled residents (Residents 128, 59, 36, and 43). Resident 128 who received lorazepam (antianxiety medication) ordered as needed (mg, unit of measurement) had no evidence of documentation the prescribing physician evaluated Resident 128 for the appropriateness of the medication. Resident 59 who received Lurasidone (Latuda) 120 milligram (mg, unit of measurement) daily for paranoid schizophrenia (a mental illness characterized by delusions and hallucinations); Resident 43 who received Risperdone (antipsychotic medication); and Resident 36 who received Cymbalta (antidepressant medication) had no monitoring for side effects every shift as prescribed by the physician. This failure had the potential for the residents to receive unnecessary medication.

Inspectors wroteBased on observation, interview, and record review, the facility had a 5.56% medication error rate when two medication errors out of 36 opportunities were observed during medication administration for one resident (Resident 60). This failure had the potential to compromise the resident's medical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were appropriately stored and labeled during an inspection of two medication rooms and randomly selected medication carts when the following was found: 1. An emergency kit (e-kit, a box containing medication needed for immediate administration) containing injectable (put into the body using a needle and syringe) medications contained expired medications. 2. Medications that required refrigeration were stored inside the medication carts. 3. An injectable medication pen was opened and used with no date. 4. Liquid nutritional supplement was expired. These failures had the potential for the administration of expired or deteriorated medications or biologicals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and ensure food under sanitary conditions for one of two sampled residents (Resident 94) when resident food brought by a family member (FM) was not properly stored, labeled and dated. This failure had the potential for food borne illness and food contamination.