Grand Cove Nursing & Rehabilitation Center

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure medical records were complete and accurately documented for 1 (#R1) of 4 residents reviewed for medical record accuracy. This deficient practice had the potential to affect a census of 87.

Inspectors wroteBased on interview, and record review, the facility failed to ensure medical records were accurately documented and maintained in accordance with professional standards of practice for 2 (#1 and #9) residents out of 6 (#1, #2, #3, #4, #6, #9) sampled residents investigated for wound care in a total sample of 9 residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to develop and/or implement a comprehensive person-centered plan of care and/or physician's orders for (#2) out of 11 (#1, #2, #3, #4, and #R1-#R7) sampled resident as evidenced by failing to identify and implement interventions for refusal of care for Resident #2.

Inspectors wroteBased on record reviews and interviews, the facility failed to revise a comprehensive person-centered plan of care for 1 (#1) out of 11 (#1, #2, #3, #4, and #R1-#R7) sampled resident as evidenced by failing to revise a care plan with changes in ADL (activities of daily living) care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide services to meet professional standards in accordance with the resident's written plan of care by failing to administer daily medication on time as ordered for 3 (#1, #R1 and #R2) out of 11 (#1- #4 and #R1 - #R7) sampled residents. The deficient practice had the potential to effect a census of 87.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the resident's quarterly MDS (Minimum Data Set) assessment was completed and submitted to CMS (Center for Medicare and Medicaid Services) in a timely manner for 1 (#44) of 5 (#29, #41, #44, #46, #56) residents investigated for resident assessments in a final sample of 30 residents.

Inspectors wroteBased on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for use of antiplatelet medication for 1 (#56) out of 30 sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (#9, #41) out of a final sample of 30 residents. The deficient practice had the potential to affect a total census of 84 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that ensured accurate administration of medication to meet the needs of 1 (#72) of 6 residents observed during medication administration. The deficient practice had the potential to effect the facility census of 84 residents.

Inspectors wroteBased on observation and interview, the facility failed to serve food in accordance with professional standards for food service safety as evidenced by failing to ensure: 1. dietary staff with facial hair utilized a hair restraint to prevent hair from contacting food; 2. dietary staff utilized gloves when handling and preparing food; and, 3. dietary staff utilized proper sanitary procedures when serving ice with a ice scoop. These deficiencies had the potential to affect the entire census of 80 residents who consumed food and beverages prepared in the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure a reentry MDS (Minimum Data Set) assessment was completed timely for 1 (Resident #14 ) out of 25 sampled residents. The deficient practice had a potential to affect a total census of 73.

Inspectors wroteBased on record reviews and interview, the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 1 (#68) out of 3 (#38, #3, #68) residents' records reviewed in a final sample of 25 residents. The deficiency had the potential to affect a census of 73.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medication was stored securely and discarded upon expiration and was not available for improper resident use as evidenced by an expired medication being left in an unlocked refrigerator designated for resident food storage. The facility had a census of 73.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to maintain an effective infection control and prevention program as evidenced by staff failing to put on the appropriate Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) and perform hand hygiene and glove changes when indicated during a nephrostomy tube dressing change for 1 (#280) of 2 (#61, #208) residents who were investigated for catheters in a final sample of 25 residents.

Inspectors wroteBased on record reviews and interviews, the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 1 (#1) out of 3 (#1, #2, #3) residents' records reviewed. The deficiency had the potential to affect a census of 84.

Inspectors wroteBased on record review and interview, the facility failed to maintain a complete medical record on each resident for 1 (#1) out of 3 (#1, #2, #3) sampled residents. This was evidenced by failing to ensure medications were documented as administered on the MAR (medication administration record) after administering to the resident. This deficient practice had the potential to affect a census of 84 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure nursing staff effectively notified the physician of a resident's injury for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in an immediate jeopardy for Resident #1 on Friday, 10/13/2023 at 7:30 p.m., when S5LPN noted Resident #1's right arm tucked behind her back. She observed the resident's whimpering and her right arm was swollen and puffy. S5LPN notified S9MD's office via fax at approximately 10:30 p.m. that same evening when the physician's office was closed and would have remained closed and not staffed for the weekend. On Monday, 10/16/2023 at 7:11 a.m. S3LPN observed the injury, notified the doctor by phone and sent the resident to the hospital for evaluation and treatment where she was diagnosed with a fracture of the right arm. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#1) of 3 (#1, #2 and #3) sampled residents. The facility failed to ensure nursing staff: 1. effectively communicated a change in Resident #1's condition to a physician and 2. intervene by following up with the physician after the identified a change in condition for Resident #1 when she continued to display signs of injury and pain. This deficient practice resulted in an immediate jeopardy for Resident #1 on Friday, 10/13/2023 at 7:30 p.m., when S5LPN noted Resident #1's right arm tucked behind her back. She observed the resident whimpering and her right arm was swollen and puffy. S5LPN notified S9MD's office via fax at approximately 10:30 p.m. [...]

Inspectors wroteBased on records reviewed and interviews, the facility failed to implement the person centered care plan by not following physician orders for 4 (#1, #15, #46, #57 and #58) residents out of a total of 32 sampled residents as evidenced by failing to: 1. obtain a monthly weights as per facility policy and procedure for Resident #1 and, 2. document dietary intake amount for each meal as ordered for Residents #1, #15, #57 and # 58, and, 3. obtain laboratory testing as ordered for Resident #46 This deficient practice had the potential to affect the 79 residents who resided in the facility.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to protect the residents' right to be free from physical abuse by other residents for 1 (#27) out of 32 sampled residents. The facility failed to protect Resident #27 from physical abuse when Resident #32 shoved Resident #27 in the left shoulder on 2/28/2023. The facility had a census of 79.

Inspectors wroteBased on record review and interview, the facility failed to refer residents with newly diagnosed mental disorders or had a significant change in their mental condition to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) for evaluation and determination for 2 (#31, #48) of 5 residents (13, 31, 46, 48, 58) investigated for PASARR in a final sample of 32 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that acceptable parameters of nutritional status was maintained for 2 (Resident #1, Resident #58) out of 4 (#1, #15, #57, #58) residents reviewed for nutrition. The facility failed to: 1. obtain a weight monthly for Resident #1, and 2. identify significant weight loss for Resident #58. This deficient practice had the potential to affect a census of 79.

Inspectors wroteBased on observation, review, and interview, the facility failed to ensure food products were discarded on or before the expiration date and discard canned goods with compromised seals in the dry storage room. This deficient practice has the potential to effect the 79 residents that eat meals in the facility.