Grand River Health Care Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for one (#6) of four residents reviewed for accidents out of 28 sample residents. Specifically, the facility failed to ensure swallowing precautions were implemented for Resident #6, who had a diagnosis of dysphagia (difficulty swallowing). Resident #6 was identified as being at risk for choking upon admission. On 9/16/25, the resident experienced a choking episode in the dining room. The Heimlich Maneuver was not needed; however, the nurse had to reposition the resident forward and to the side in order for him to successfully expel chunks of food with liquid from his throat. On 9/29/25 Resident #6 experienced another choking episode after drinking water. [...]

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews. Specifically, the facility failed to complete a performance review of certified nurse aide (CNA) at least once every 12 months.

Inspectors wroteBased on record review and interviews, the facility failed to provide ongoing communication to residents about their rights; and failed to inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility for one (#50) of three residents reviewed out of 28 sample residents. Specifically, the facility failed to provide Resident #50 with a written copy of the facility's room change/move policy and procedure upon the resident's request.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#10) of five residents reviewed for medication errors out of 28 sample residents. Specifically, the facility failed to:-Ensure that Resident #10 received warfarin (an anticoagulant medication), a medication with a narrow therapeutic index (a medication where the difference between an effective dose and a toxic dose is very small); and,-Determine how the significant medication error occurred and provide education to nursing staff in order to prevent future occurrences.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to:-Ensure Resident #3's wound care supplies were not taken into Resident #33's bathroom during Resident #33's wound care dressing change; and,-Ensure registered nurse (RN) #3 followed enhanced barrier precautions (EBP), including wearing a protective gown when providing wound care for Resident #33.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner for two out of four kitchens. Specifically, the facility failed to ensure: -Staff used adequate hand hygiene while serving meals and touched ready-to-eat food appropriately; and, -Residents were offered and encouraged hand hygiene prior to meals.

Inspectors wroteBased on record review and interviews, the facility failed to develop and revise comprehensive care plans for each resident that included the instructions needed to provide effective and person-centered care for one (#10) of four residents out of 30 sample residents. Specifically, the facility failed to: -Update and personalize care plans for Resident #10 who was at high risk for falls; -Update Resident #10's dementia care plan documenting interventions; -Initiate a care plan for Resident #10's refusals to wear oxygen; -Personalize Resident #10's behavioral care plan with interventions to deter his verbal aggression; and, -Personalize Resident #10's care plan for his refusals of care.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for one (#27) of four residents reviewed for accident hazards out of 30 sample residents. Specifically, the facility failed to ensure timely, effective and properly communicated interventions were in place to prevent skin injuries and the recurrence of skin injuries to Resident #27.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident who upon admission displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct an assessed problem and/or to attain the highest practicable mental and psychosocial well-being for one (#50) of four residents reviewed out of 30 sample residents. Specifically, the facility failed to: -Initiated therapy as recommended by preadmission screening and resident review (PASRR) Level II until four weeks later and after Resident #50 was experiencing mental health concerns: -Identify the Resident #50 triggers and past trauma to minimize being retraumatized; and, -Allow Resident #50 to have the bed of her preference due to a past traumatizing experience to minimize her trouble sleeping and night terrors.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the facility medication administration observation error rate was 7.32% or three errors out of 41 opportunities.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one out of three units at the facility. Specifically, the facility failed to ensure housekeeping staff: -Following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (remote controls, light switches, door handles and drawer pulls); -Performed hand hygiene when appropriate; -Cleaning the toilet bowl appropriately; -Cleaned a resident's room from cleaner areas to dirtier areas to avoid spreading dirt and microorganisms; and, -Adhered to disinfectant cleaning guidelines.