Grand Rapids Care Center

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure food and drink items were stored in a manner to prevent spoilage. This had the potential to affect all 28 residents who received food and drink from the kitchenette. The facility identified one (#8) resident who received nothing by mouth. The facility census was 29.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure a resident centered care plan was developed in a timely manner for a resident who smoked. This affected one (#5) of two residents reviewed for smoking. The facility census was 29.

Inspectors wroteBased on observation, staff interview, review of the medical record, review of infection control signage, and review of the facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were followed. This affected one (#1) of one resident reviewed for EBP. The facility census was 29.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of a facility submitted Self-Reported Incident (SRI), review of the facility incident log, review of witness statements, staff and resident interview, and review of the facility policy, the facility failed to ensure residents were free from staff-to-resident verbal abuse. This affected one (#15) of three residents reviewed for abuse. The facility census was 30.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of a facility initiated Self-Reported Incident (SRI), review of the facility incident log, review of witness statements, staff interview, and review of the facility policy, the facility failed to ensure staff reported allegations of staff-to-resident verbal abuse timely. This affected one (#15) of three residents reviewed for abuse. The facility census was 30.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure resident care plans were revised to included supports and interventions for depression and related antidepressant use. This affected one resident (#3) of five residents reviewed for unnecessary medications. The facility census was 30. Findings Include: Review of Resident #3's medical record revealed an admission date of 10/02/23. Diagnoses included type II diabetes, heart disease, peripheral vascular disease, depression, osteomyelitis, pain, kidney cancer, prostate cancer, and lymphedema. Review of Resident #3's Minimum Data Set (MDS) assessment, 04/07/24, revealed Resident #3 was cognitively intact. Resident #3 displayed no behaviors during the review period. [...]

Inspectors wroteBased on review of the medical record, observation, interview, and policy review, the facility failed to ensure a resident was timely referred for dental services for missing dentures. This affected one (#5) of one resident reviewed for dental services. The facility census was 30.

Inspectors wroteBased on the review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report, staffing schedule, posted daily staffing sheets, staff time sheets, and staff interview, the facility failed to submit accurate information in the PBJ for the first quarter of 2024. This had the potential to affect all residents. The facility census was 30. Findings Include: Review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed the facility triggered for not having licensed nursing coverage 24 hours a day in the first quarter of 2024. The specific days identified were 10/05/24, 12/24/23, 12/25/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, 12/30/23, and 12/31/23. [...]

Inspectors wroteBased on review of resident personal fund account documentation and staff interview, the facility failed to ensure witness signatures were obtained when personal fund accounts were opened. This affected two (#6 and #7) of five residents reviewed for personal fund accounts. The census was 28.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure the resident and resident representative were notified of changes in medication and test results. This affected two (#5 and #19) of two residents reviewed for notification of change. The facility census was 28.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure resident rooms were maintained in good repair. This affected one (#6) of 28 residents reviewed. The facility census was 28.

Inspectors wroteBased on medical record review, review of a self-reported incident, resident representative interview, staff interview, and facility policy review, the facility failed to timely report allegations of misappropriation to the State Survey Agency. This affected one (#19) of one resident reviewed for misappropriation. The facility census was 28.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure interventions were implemented to prevent pressure ulcer development or worsening of a current pressure ulcer. This affected one (#28) of two residents reviewed for pressure ulcers. The facility census was 28.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure physical therapy treatments and range of motion interventions were consistently implemented for a resident to prevent contracture and decreased joint mobility. This affected one (#28) of one residents reviewed for range of motion. The facility census was 28.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure dependent residents received timely care and services to address bowel incontinence. This affected one (#28) of one residents reviewed for incontinence. The facility identified eleven residents as occasionally or frequently incontinent of bowel. The facility census was 28.

Inspectors wroteBased on medical record review, resident representative interview, staff interview, review of witness statements, and review of a self-reported incident, the facility failed to maintain accurate documentation in the medical record. This affected one (#19) of 13 resident records reviewed. The facility census was 28.

Inspectors wroteBased on review of employee personnel files and staff interview, the facility failed to complete performance reviews for state tested nurse aides (STNAs) at least once every 12 months. This affected two (#230 and #240) of two STNAs reviewed for annual performance evaluations. This had the potential to affect all 28 residents in the facility. The census was 28.