Grand River Health Care

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one resident (Resident #1) from abuse on 01/05/26, when the Director of Nursing (DON) and the Administrator forced the resident to remove soiled clothing by physically restraining the resident's arms, hands, and ripping the soiled clothing off while the DON yelled curses and obscenities at the resident. As a result, the resident complained of arm pain and said they hurt me. Multiple, small, light-colored bruises were observed. The resident was transported to the emergency room for evaluation. The facility also failed to provide continued protection when the DON and Administrator were not immediately removed from the facility, per policy, and they continued to provide oversight for all residents until 01/06/26. The facility census was 31. The administrator was notified on 01/08/26 at 1:22 P.M. [...]

Inspectors wroteBased on record review and interview, the facility failed to immediately report an allegation of abuse to the state survey agency. This effected one of four sampled residents (Resident #1). The facility census was 31. Review of the facility policy titled, Abuse Prohibition Protocol Manual, dated 11/28/2016 showed: -It is the policy of the facility that each resident will be free from verbal, mental or physical abuse and corporal punishment; -Residents will be protected from abuse, neglect and harm while they are residing at the facility;-No abuse or harm of any type will be tolerated; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish; -Examples of physical abuse include: [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one residents (Resident #2) right to be free from physical abuse when Resident #1 hit Resident #2 on the arm on two separate occasions. The facility census was 28. Review of the facility Abuse Policy, undated, showed:- It is the policy of the facility that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property, and exploitation, corporal punishment, or involuntary seclusion;- The resident will be protected from abuse, neglect, and harm while they are residing at the facility;- Abuse is the willful infliction of injury, unreasonable restriction, threat or punishment with resulting physical harm or pain, or mental pain or deprivation by an individual; - Abuse is any intentional act that causes harm or potential harm to a resident. [...]

Inspectors wroteBased on record review and interview, the facility failed to keep one resident (Resident #2) free from verbal and physical abuse when Nurse Aide (NA) A held resident's arms down and cussed at resident (Resident #2) and when Licensed Practical Nurse (LPN) A yelled at resident (Resident #2) and forced the resident to wear a bi-pap mask (A device that forces oxygenated air through mask that is suctioned against a person's face to provide respiratory support) against the resident's will . The facility census was 26. Review of facility policy, dated 11/2017, showed: -It is the policy of the facility that at each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property, and exploitation, corporal punishment, or involuntary seclusion. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to assure one resident (Resident #1) was free from misappropriation of his/her property when the resident's narcotic medications were found missing from the facility. The facility census was 26. Review of facility's abuse policy, dated 11/2017, showed: -It is the policy of the facility that at each resident will be free from abuse. Abuse can include misappropriation of resident property -All employees who have been alleged to commit abuse will be suspended immediately pending investigation. -If allegation is substantiated there is a potential that the employee will be terminated, added to the Employee Disqualification List and not allowed to work in a nursing home, disciplined by their licensing agency, and charged with a crime. Review of facility policy, Scheduled II-V Medications, undated, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to report to the state survey agency and law enforcement, misappropriation of resident property (missing narcotics), when the facility became aware on 3/11/25 that one resident (Resident #1) had one bubble pack card of a narcotic medication, hydrocodone-acetaminophen 7.5-325mg (a controlled drug used to relieve severe pain) missing. The facility census was 26. Review of facility abuse and neglect policy, dated 11/2017, showed: -The facility will ensure that any reasonable suspicion of crimes committed against a resident of the facility will be reported to the appropriate Law Enforcement Agency as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a record of the dishwasher chemical tests, label and date all foods, dispose of expired foods, properly store glasses and cups, failed to ensure kitchen was clean and in good repair, and failed to ensure walk-in cooler was in good repair. The facility census was 27. A policy regarding dietary services and food storage was requested but not provided. 1. Continuous observation of the kitchen on 2/24/25 beginning at 9:44 A.M. showed: - Expired 8 oz. Always Save baking cocoa best by date was 6/19/22; - Expired10 lb. Clabber Girl baking powder best by date was 9/2021; -No open date labeled on 1 gallon Kikkoman soy sauce; -.49 oz. Supreme Tradition parsley flakes with no open or best by date; -11 lb. [...]

Inspectors wrote2. Review of Resident #15's Quarterly MDS, dated [DATE], showed: - Cognitive skills moderately impaired; - Independent with eating and transfers; - Diagnoses included: Diabetes mellitus, depression, high blood pressure, schizophrenia ( a serious mental illness that affects how a person thinks, feels, and behaves) and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's POS, dated 1/25/25 - 2/25/25, showed: - Start date: 3/5/24 - Check and record blood sugar daily; - Start date: 7/22/24 - Humulin R (short acting) insulin per sliding scale. The order did not indicate how often it was to be administered; - Start date: 6/19/24 - Trelegy Ellipta 100-62.5 - 5-25 micrograms (mcg.), inhale one puff daily and rinse mouth after use for COPD. [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure they provided a reasonable accommodation of needs when they made residents, some with potential gait instabilities, from entering a dark restroom connected to their room and having to cross the whole restroom to flip the light switch to get the light to illuminate. This affected 11 of 30 rooms. The faciltiy census was 27. 1. Observation on 2/5/25 stating at 2:36 P.M., showed the the restrooms between rooms 201/203, 202/204, 205/207, 206/208, 209, and 210/212 had a shared restroom. Both sides had a light switch. The light switch was located just inside the restroom on the interior wall on both sides. To get to the other light switch the resident would need to pass by the sink, toilet, and get to the other wall with the light switch. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote an environment respectful of the rights of each resident to make choices about significant aspects of their lives when staff did not respond to shower preferences for two of the 12 sampled residents, (Resident #2 and Resident #3) and when staff failed to assist Resident #3 to shave per his/her preference. The facility census was 27. The facility did not provide a policy regarding showers or shaving. 1. Review of Resident #3's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/20/24 showed: - Cognitive skills intact; - Independent with showers, dressing, personal hygiene and transfers; - Always continent of bowel and bladder; [...]

Inspectors wroteBased on interview and record review the facility staff failed to ensure residents (Resident #1, #4, #6, #15) had timely access to their personal funds on the weekend. This affected four of the 12 sampled residents. The facility census was 27. Review of facility policy Guidelines for Maintaining the Resident Trust Fund Account, revised, 8/20/19, showed: - The resident and/or legal representative, upon request will have reasonable access to the resident's personal funds during normal business office hours; - If funds are requested for weekend use, funds should be requested during normal business hours on Friday or if outside normal business/banking hours, facility staff may contact a member of facility management for access; 1. Review of Resident #1's Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/2/24, showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment when the facility failed to maintain comfortable temperatures in the shower room, fill, sand, and paint drywall patches, maintain facility furniture in good repair, ensure all call lights were functional, flooring was clean and in good repair and replace wallpaper as needed. This affected all residents in the facility. The facility census was 27. A policy regarding Maintenance and Upkeep of Facility was requested but provided. Review of the Maintenance Work Log at the nurses' station showed: - A binder containing repair requests entered in by staff for the maintenance department to complete; - Entry: room [ROOM NUMBER] hole in wall needs filled, marked down as fixed; - Entry: Shower room drain won't go down (not fixed) 2/18/25; Observation on 2/24/25 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff developed and updated a care plan consistent with resident's specific conditions and needs which affected two of the 12 sampled residents, (Resident #11, #26). The facility census was 27. A policy regarding care plans was requested but not provided. 1. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/2/24, showed: - Cognition severely impaired; - Total assist of all Activities of Daily Living; Mobility, Transfers and Hygiene - Diagnosis: Anemia, hypertension (high blood pressure), diabetes, seizure disorder, schizophrenia (mental disorder with a disruption in thought processes), Post Traumatic Stress Disorder (PTSD) (mental health condition from witnessing a traumatic event); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided services that met professional standards of quality of care when staff failed to have medications available for two of the 12 sampled residents, (Resident #6, #15) and failed to clarify a sliding scale insulin order for Resident #15. The facility census was 27. The facility did not provide a policy for ordering medications. 1. Review of Resident #15's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/15/24, showed: - Cognitive skills moderately impaired; - Independent with eating and transfers; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had fresh water at bedside that was easily accessible to the residents. This affected three of the 12 sampled residents, (Resident #15, #22 and #26). The facility census was 27. Review of the facility's undated policy titled, Hydration, showed staff were directed to do the following: - Each resident is supplied with sufficient fluid intake to maintain proper hydration; - Fresh water is distributed each shift, pitchers and glasses are within reach of the resident and residents who are unable to pour and drink independently will be given assistance by the staff. 1. Review of Resident #15's care plan, revised 11/30/24 showed; - The resident had a diagnosis of constipation; - Will follow diet as ordered by the primary care physician; - Will maintain adequate hydration daily. [...]

Inspectors wrote2. Review of Resident #22's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Independent with eating dressing, personal hygiene and transfers; - Diagnoses included psychotic disorder ( a mental illness that causes a person to lose touch with reality), chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing), and diabetes mellitus. Review of the resident's POS, dated 1/25/25 - 2/25/25, showed; - Start date: 9/27/23 - O2 at 2L/NC (Liters per Nasal Cannula) with ambulation, none required at rest for acute respiratory failure with hypoxia (lack of oxygen to the tissues); - Start date: 8/13/23 - Ipratropium-albuterol solution for nebulization 0.5 mg. -3 mg./3 ml four times a day for shortness of air. Review of the resident's care plan, revised 1/28/25, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made five medication errors out of 26 opportunities for error which resulted in a medication error rate of 19.23%, which affected four of the 12 sampled residents, ( Resident #2, #22, #15 and #9). The facility census was 27. Review of the facility's undated policy titled, Medication, Administration Guidelines, showed staff were directed to do the following: - It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies; - Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired medications, and biologicals stored within the medication room and the medication cart, failed to date an opened vial of Influenza vaccine, and failed to ensure resident's cigarettes and personal money was not stored in the medication cart. This had the potential to affect all residents within the facility. The facility census was 27. Review of the facility's undated policy titled, Medication Administration Guidelines, showed: - It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies; - Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the required two step tuberculosis (TB, a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered upon hire for seven random sampled, newly hired employees, and failed to use proper handwashing in between tasks, and failed to use enhanced barrier precautions during wound care for resident #79, which affected one of twelve sampled residents. The facility census was 27. Review of the facility's undated Tuberculosis (TB) Control policy showed: -Initial examination: Provide a tuberculin skin test to all employees during pre-employment procedures. -If the initial skin-test result is 0-9mm, a second test should be given at least one week and no more than three weeks after the first test. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from abuse when Resident #12 threatened harm to Resident #9. The facility census was 27. Review of the facility's undated Abuse Prohibition Protocol Policy, showed: - It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion - Additionally, residents will be protected from abuse, neglect and harm while they are residing at the facility; - No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection; - The objective of the abuse policy is to comply with the seven step approach to abuse and neglect detection and prevention. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of 12 sampled residents (Resident #8) when staff failed to notify the physician of a resident's change of condition in a timely manner. The facility census was 27. A policy regarding physician notification was requested but not provided. 1. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/8/25, showed: -Severe cognitive impairment; -Dependent on a wheelchair for mobility; -Diagnoses included: Diabetes, high blood pressure, dementia, anxiety, and depression. Review of nursing progress notes, dated 2/20/25-2/24/25, showed: -No documentation regarding the resident's upper respiratory condition; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident, (Resident #1) was free from verbal and physical abuse when Certified Nursing Assistant (CNA) A grabbed the resident's arm, jerking him/her back into the wheelchair, while yelling and cursing at the resident. The facility census was 27. Review of the facility's Abuse Prohibition policy, dated November 2017, showed: -It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) was free from abuse when a staff member forcibly used the resident's own hand to hit himself/herself in the face multiple times. This affected one of four sampled residents (Resident #1). The facility census was 28. Review of the facility provided, Abuse Prohibition Policy dated March 2012 showed: -It is the purpose of this facility to prohibit mistreatment, neglect abuse of resident and misappropriation of resident property. -Abuse is defined as the willful infliction of injury,unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. -All employees of this facility are mandated reporters. -All allegations of abuse, neglect,exploitation, mistreatment, injuries of unknown sources, will be reported immediately. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an alleged violation of potential physical abuse was reported immediately, but not later than two hours after the allegation was made, to officials in accordance with State law, including the Survey Agency for one sampled resident (Resident #1) out of four sampled residents. The facility census was 28 residents. Review of the facility provided, Abuse Prohibition Policy dated March 2012 showed: -It is the purpose of this facility to prohibit mistreatment, neglect abuse of resident and misappropriation of resident property; -All employees of this facility are mandated reporters; -All allegations of abuse, neglect,exploitation, mistreatment, injuries of unknown sources, will be reported immediately. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (Resident #1), of three sampled residents, was free from the use of physical restraint when staff members used their bodies to wrap their arms around the resident to entrap the resident's arms down to his/her side, not allowing movement from the resident, while the nurse administered an intramuscular (IM) injection to the resident for aggressive behaviors towards staff. The facility census was 29. Review of the facility policy Behavioral Interventions Catastrophic Reactions (an overreaction or inappropriate behavior associated with a resident who has dementia (a progressive condition that causes a decline in thinking, remembering, and reasoning, that interferes with daily life,)) from the Special Care Unit Manual, Section 6, dated April 2006 showed staff should do the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate behavioral health interventions for one resident (Residents #1 ) who exhibited behaviors that escalated to a catastrophic reaction, culminating in the use of an antipsychotic (previously known as major tranquilizers: are a class of medication primarily used to manage psychosis: a mental disorder characterized by a disconnection from reality.)medication injection. The facility census was 29. Review of the facility provided policy Behavioral Interventions, dated April 2006 showed: -Catastrophic reaction is the over reactive or inappropriate behavior associated with the resident. This behavior occurs when the resident misunderstands or cannot cope with a distressing physical or environmental situation. A catastrophic reaction can occur when a resident becomes overwhelmed. [...]

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure one dietary employee washed his/her hands after touching the lid to the trash can several times. This practice potentially affected the 26 residents who ate food from the kitchen. The facility census was 26 residents. Review of the Handwashing Policy dated May 2015, showed: -If using gloves, remove gloves; -Roll down paper towels (some facilities may have self-dispensing paper towels); -Turn on water and run until warm; -Wet hands and forearms with warm water; -Lather hands with antiseptic soap; -Wash hands, giving particular attention to the areas between fingers, around cuticles, and under fingernails; -Wash forearms as well; -Rinse thoroughly with warm water, beginning at the top of the forearm; -Wipe hands dry with clean paper towel; -Turn off water with paper towel and dispose of paper towel; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat three of 13 sampled residents (Resident #4, #15 and #21) with dignity and respect when staff did not knock on the resident's door, wait for resident's response before entering, and announcing themselves. The facility census was 26. Review of the undated Resident Rights Policy showed Social Service Department will review Resident Right and Health Care Directives on admission with all residents and annually thereafter, both orally and in writing in a language the resident understands of his rights and rules/regulations including grooming, resident conduct, and responsibilities during facility stay. All residents will be informed of resident rights, regardless of physical, emotional or mental impairment. The rights included treating residents with privacy and respect. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to deliver Saturday mail to three of (Resident #21, #3, and #1) 16 sampled residents. The facility census was 26. Review of the undated Resident Rights Policy showed: -Social Service Department will review Resident Right and Health Care Directives on admission with all residents annually thereafter, both orally and in writing in a language the resident understands of his rights and rules/regulations including grooming, resident conduct, and responsibilities during facility stay. All residents will be informed of resident rights, regardless of physical, emotional or mental impairment. RIGHTS: -Resident [NAME] of Rights -Renew annually Resident Rights -To be fully informed -Participate in their own care -Communicate freely 1. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected three of 12 sampled residents, (Resident #4, #6 and #21). The facility census was 26. Review of the facility's undated policy for perineal care, showed, in part: - The purpose is to clean the perineum and to prevent infection and odor; - Assist the resident to lay on their side and flex their knees; - Use one gloved hand to stabilize and separate the perineal folds, with the other hand, wash from front to back; - Rinse and pat dry; - Use a new wash cloth and wash around the anus. 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide documentation of the pharmacist's recommendations for two of 12 sampled residents, (Resident # 4 and #13). The facility census was 26. The facility did not provide a policy for consultant pharmacy services and/or gradual dose reductions. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/4/23 showed: - Cognitive skills for daily decision making, moderately impaired; - Required extensive assistance of two staff for bed mobility, transfers and toilet use; - Lower extremity impaired on both sides; - Always incontinent of bowel and bladder; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made five medication errors out of 25 opportunities for error, resulting in a medication error rate of 20%. This affected four residents sampled for medication administration (Residents #2, #24, #14, and #1). The facility census was 26. Review of the Cyclosprine eye drops manufacturer's guidelines, dated November 2022 showed: - How to use: Tilt your head back, look upward, and pull down the lower eyelid to make a pouch. Hold the dropper directly over your eye and place one drop into the pouch. Look downward, gently close your eyes, and place one finger at the corner of your eye (near the nose). Apply gentle pressure for 1 to 2 minutes before opening your eyes. This will prevent the medication from draining out. [...]

Inspectors wroteBased on observation, interviews and record review, the facility staff failed to prevent a significant medication error, when staff did not follow standards of practice when staff failed to prime the insulin pens with two units prior to administration and failed to allow the insulin pen to remain in the injection site for at least 6 seconds for three of 12 sampled residents, (Resident #1, #14 and #24) and failed to transcribe a physician order into the resident's electronic chart and into the Medication Administration Record (a record used to document medications given to a resident (MAR), failed to document doses of insulin were given and failed to follow a physician's order as directed for one of 12 sampled residents (Resident #1). The facility census was 26. Review of the facility's undated subcutaneous injection policy showed: [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medication was not left at a residents bedside which affected one of 12 sampled residents (Resident #17), failed log temperatures on the medication storage room refrigerator and prevent ice buildup, failed to refrain from using the medication storage refrigerator to store staff drinks, failed to destroy medication for a resident who had expired and failed to ensure both staff signed the narcotic count book at shift change. The facility census was 26. Review of the facility's undated Medications, Self-Administration, Self-Storage, Leave at Bedside policy showed: - The resident has a right to self-administer medication unless the interdisciplinary team has determined that this practice is unsafe for an individual resident. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to follow proper infection control practices during medication pass when staff did not wash or sanitize their hands between residents which affected one of 12 sampled residents (Resident #2), change out their gloves after coming in contact with dirty surfaces which affected one resident(Resident #6), did not sanitize the port of the feeding tube for one resident (Resident #6), and did not place supplies on a clean surface, which affected four resident (Resident #1, #2, #14 and #24) and when staff threw wound supplies directly on the floor which affected one sampled resident (Resident #21). The facility census was 26. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement, follow and monitor an antibiotic stewardship program when staff did not monitor infections and antibiotics on a monthly control log, trend the infections and assess to determine if the correct antibiotic was used for the correct length of time for two of 12 sampled residents (#1 and #11). The facility census was 26. Review of the facilities undated Antibiotic Stewardship Program policy showed: -Facility is implementing an antibiotic stewardship program that will help prevent unnecessary use of antibiotics. -The Adverse reaction of using unnecessary antibiotics can result in adverse drug reactions or interactions, the development of Clostridium difficile infections the emergence of multi-drug resistant organisms, antibiotic failure, increased mortality and greatly increased costs. [...]

Inspectors wroteBased on record review and interviews, the facility failed to assure they followed their policy when they failed to document the residents' choice of code status in such a way to be readily accessible to staff in the event of an emergency. This affected one sampled resident (Residents #178). The facility census was 26. Review of the undated Advance Directive Policy showed: -Upon admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive. -Upon admission of a resident, the social services designee will inquire of the resident; and/or his/her family members, about the existence of any written advance directives. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents and injuries when transferring one of 12 sampled residents, (Resident #4) during the use of a gait belt (a safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) transfer and when staff failed to report, document and investigate when staff lowered Resident #4 to the floor. The facility census was 26. Review of the facility's undated gait belt policy, showed, in part: - The purpose is to provide better control and balance while assisting residents with ambulation and transfer; - Apply belt to resident's waist, tighten to fit snugly with the buckle at the side; - Face the resident; - Bend your knees and place your hands around the gait belt on each side of the resident's waist; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to assess placement of a gastrostomy tube (g-tube (a tube placed into a patient's stomach through the abdominal wall as a means of feeding them when they are unable to eat) using the current standard of practice, failed to follow proper infection control practices when staff did not change out their gloves after coming in contact with dirty surfaces and failed to ensure correct procedures were followed when medications were administered through the g-tube. This affected one resident (Resident #6) out of 12 sampled residents. The facility census was 26. Review of the facility's undated Standard and Transmission Based Precautions policy showed standard precautions will be used in the care of all residents regardless of their diagnosis, or suspected confirmed infection status. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to act promptly upon the grievances of the resident council members concerning issues of resident care and life in the facility and failed to communicate back with the resident council regarding their concerns as reported by 15 of 15 residents, who participated in a group interview. The facility census was 37. Review of the facility policy for Residents Rights dated 4/06 showed: -It is the purpose of this facility to meet the Federal and State Mandate in respects to resident rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. A facility must protect and promote the rights of each resident. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' grievances were fully addressed and failed to maintain complete documentation of grievances received, steps taken to resolve the grievance, notification of the residents of the results of the grievance and follow up with the residents to ensure the problem/concern was resolved for two sampled residents (Resident #6 and #32). The facility census was 37. Review of the facility policy for Grievance Protocol dated 4/06 showed: -The purpose of the Grievance/Complaint Report and Grievance Log is to provide a written record of each resident and family concern and to insure proper follow-up through the appropriate discipline. -The Social Service Director (SSD) is responsible for the program, although the Administrator is ultimately responsible for the proper implementation of the program.; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure staff provided necessary care and services in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of 21 sampled residents Resident #25. Staff also failed to respond timely when one resident, Resident #36 had a change in condition. The facility census was 37. 1. Review of the facility policy titled Condition Change, Resident (Observing, Recording and Reporting) dated March 2015 included the following: - Purpose: To observe, record, and report any condition change to the attending physician so that proper treatment can be implemented; - After changes in physical or mental function, monitor for the following (included): o Observe personality changes; o Observe for alterations in consciousness; o Observe for incontinence; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to monitor weights, notify the physician of the Registered Dietician's (RD) recommendations and of weight loss for one resident (Resident #16) of 21 sampled residents. The facility census was 37. Review of the facility policy for Dietitian Consultant Reports dated 5/15 showed: -The Dietitian will complete a consultation report prior to completing an exit interview with the Administrator and Dining Services Manager or will fax or email the completed report the next working day; -The consultant report must reflect what was accomplished in the visit which may include, but is not limited to: assessment and monitoring of nutritional needs of the resident; -Recommendations should be completed within five working days of the monthly visit; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner to prevent infection or the possibility of infection when they did not change gloves and wash their hands between dirty and clean tasks which affected two of 21 sampled residents (Resident #25 and #27) and failed to follow the facility policy for Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) when staff failed to wear the appropriate personal protective equipment (PPE) when caring for a resident (Resident #36) in the Observation Unit for COVID-19 and failed to wear a facemask while preparing food in the dietary department. The facility census was 37. Review of the facility policy for Gloves, dated 3/15 showed: [...]

Inspectors wroteBased on record review and interview, the facility failed to notify a resident's physician and guardian immediately when the resident (Resident #36) had a significant change in condition. The resident had a history of being hospitalized while living at the facility. The facility census was 37. Review of the facility policy titled Condition Change, Resident (Observing, Recording and Reporting; includes Fall or Injury), dated March 2015 included the following: - Purpose: To observe, record, and report any condition change to the attending physician so that proper treatment can be implemented; - After all resident falls, injuries or changes in physical or mental function, monitor for the following (included): o Observe personality changes; o Observe for alterations in consciousness; o Observe for incontinence; o Observe for generalized weakness; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided transfer or discharge notification to residents and their responsible party and the reasons for the transfer/discharge in writing in a language they understood. This affected three of 18 sampled residents (Residents #1, #23 and #36). The facility census was 37. Review of the facility policy for Discharge/Transfer of Resident dated 3/15 showed: -Discharge means to leave the facility without plans or intention to return (i.e., discharge to go home, a lower level of care or another long-term care facility).; -Transfer means to leave the facility with plans or intention to return (i.e., transfer to an acute care facility for appropriate care); -Purpose: to provide safe departure from the facility and to provide sufficient information for the aftercare of the resident: -Needed are: [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and the resident's family/legal representative of the facility's bed-hold policy at the time of transfer/discharge to the hospital for one of 21 sampled residents (Residents #1). The facility census was 37. 1. Review of the undated facility policy for Bed Hold showed: -The facility will notify all residents, and/or their representative of the bed hold guidelines. This notification shall be given: 1. Upon admission to the facility, 2. At the time of transfer to the hospital or leave, and 3. At the time of non-covered therapeutic leave. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (Resident #36), who had a history of multiple re-hospitalizations, kept a follow up appointment according to discharge orders from his/her most recent hospitalization. The facility census was 37. 1. Review of Resident #36's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/30/20 showed the following: - admission date 6/7/16; - Moderate cognitive impairment. Review of the resident's medical record showed the resident was hospitalized on the following dates: - 4/13/20 for Urinary Tract Infection (UTI), extended-spectrum b-lactamase (ESBL)-producing Escherichia coli (ecoli) grows from the urine culture - 5/22/20- acute respiratory failure with hypoxia; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure staff identified the cause of an injury and put measures in place for one resident (Resident #27), when the resident developed dark, bruised appearing areas to both outer ankles. The facility census was 37. 1. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 12/2/20 showed: -Alert and oriented and able to make decisions and answer questions appropriately; -Extensive assistance of two staff members with Activities of Daily Living (ADL's) ; -Independent with locomotion in a wheelchair; -Incontinent of bowel and bladder; -No falls or skin impairment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to change oxygen tubing weekly. This affected three residents (Residents #10, #27, #18) and had the potential to affect all residents who require oxygen while in the dining room. The facility also failed to obtain physician orders for oxygen therapy for two residents (Resident #10 and #27). Facility census was 37. Review of facility policy, Cleaning Guidelines - Oxygen Equipment, dated March 2015, showed: -All oxygen equipment are changed every seven days when heated humidification is used, and monthly when unheated humidification is used. -All concentrator outside surfaces are to be cleaned weekly by nursing personnel, and marked with date an initials; -Tubing, masks, and cannula's used with oxygen therapy should be replaced monthly and as needed (PRN), and marked with date and initials. [...]

Inspectors wroteBased on record review and interview, the facility failed to assure two of 21 sampled residents (Resident #15 and #18), who used psychotropic drugs received gradual dose reductions (GDRs) in an effort to discontinue these drugs. The facility also failed to assure as needed (PRN) orders for psychotropic drugs were limited to 14 days. The facility's census was 37. Review of the facility policy for Drug Review dated 3/15 showed: -All medications given to reach resident will be reviewed on a monthly basis in order to; review drug interactions, insure adherence to stop orders, insure accuracy in administration and evaluate medications appropriate to diagnosis; -The pharmacist reviews all federal indicators, and a monthly report is filled out to show any problem areas. The report lists any problems noted, the date and signature of the reporter; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications with a less than 5% medications error rate. Facility staff made three medication errors out of 25 opportunities for error resulting in a 12.0% medication error rate. This affected two of 21 sampled residents (Residents #6 and #18 ). The facility census was 37. Review of the facility policy for Medication Administration dated 3/15 showed: -Medications are given to benefit a resident's health as ordered by the physician. 1. Review of Resident #6's quarterly Minimum Date Set (MDS), a federally mandated assessment instrument completed by staff, dated 10/20/20 showed; -Alert and oriented and able to make decisions; -Independent with Activities of Daily Living (ADL's); -Diagnoses of heart failure, hypertension and diabetes. Review of the physician orders (POS) for February 2021 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff dated insulins when opened for resident use, failed to discard loose pills, and failed to remove expired medications from the medication cart and the medication storage room. The facility census was 37. Review of facility policy, Storage of Medications, dated March 2015, showed: -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. Review of Resident #22's physician orders, dated February 2021, showed: -Pazeo drops 0.7% (antihistamine, treats itching and redness in eyes due to allergies); instill one drop in both eyes daily as needed for allergies; order date 01/22/19. Review of Resident #14's physician orders, dated February 2021, showed: [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to prepare and provide each resident with a nourishing, palatable, well-balanced diet that meets the resident nutritional and special dietary needs. This affected two sampled residents Residents #4 and #15. The facility census was 37. 1. Review of the facility policy titled Food Preparation and Distribution, dated May 2015, included the following: - The Dining Services Department will prepare foods by methods that are safe and sanitary while conserving nutritive value as well as enhancing flavor; - Foods are prepared by methods that conserve nutritive value, flavor, and appearance Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/7/21 showed: - Moderate cognitive impairment. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff did not keep a clean kitchen. The facility census was 37. 1. Review of the undated facility policy titled Holed and Expiration Policy on Condiments, Dry Spices, etc. included the following: - Spices lose their potency of flavor over time due to dry and excessive holding, causing a quality issue. They are tossed a year after their delivery date, which is standard for spices. Spices never truly expire, but may become outdated and eventually low-quality. Spices are kept in sealed containers and stored in a clean and dry environment; - Leftovers need to be labeled and dated with current date and their expiration date. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. The facility census was 37. 1. Review of the facility's policies did not addressed foods being brought in to residents by family and other visitors. During an interview on 2/2/21 at 2:34 P.M. the Administrator and Director of Operations said: - The facility did not have an actual policy to address food being brought to residents by family and other visitors. The facility had not been allowing any food to be brought in from family or other visitors due to COVID-19 (a contagious respiratory disease thought to spread mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks).

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and provide therapy services for two residents (Residents #15, #4) when the facility placed the resident on a pureed diet due to choking and did not obtain an evaluation from a speech therapist and did not provide physical therapy after Resident #4 requested it. The facility census was 37. The facility did not provide a policy regarding therapy services. 1. Review of Resident #15 quarterly Minimum Data Set (MDS), a federally mandated assessment instrument complete by staff, dated 1/29/21 showed: -Alert and oriented with difficulty making decisions; -Limited assistance of one staff member for Activities of Daily Living (ADL's) and supervision of one staff member for eating; -Has swallowing difficulties with coughing or choking during meals during meals or when swallowing medications; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the dishwasher in the kitchen in safe operating condition. The facility census was 37. 1. Observation on 2/2/21 at 9:29 A.M. showed the dishwasher in the kitchen was not in working condition. During an interview on 2/2/21 at 10:15 A.M. the Dietary Manager said: - The dishwasher broke on the morning of 1/ 30/21. She heard clanking and the spring that helps the door open broke and the hose was not dispensing sanitizer; - The dishwasher repair man was supposed to come on 2/3/21; - The dishwasher broke down about every four months, the facility needed a new one; - All the residents were being served on disposable dishware because of the broken dishwasher, everything else was being washed in the three compartment sink. Observation on 2/3/21 at 2:43 P.M. showed the dishwasher was still not in operating condition. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public when they failed to ensure a shower drain was fastened in the shower and ensure the parking lot was free of large pot holes, potentially causing a tripping hazard. The facility census was 37. The facility did not provide a policy regarding maintenance of the facility. 1. Observation of the shower off of the 300 hall showed a drain cover in the shower was not fastened to the drain line enabling the cover to be moved from the drain line uncovering approximately a two-inch hole. 2. Observation on 2/1/21 at 10:00 A.M. throughout the survey showed seven potholes in the parking lot of various sizes. The sizes ranged from a grapefruit to beach ball size that were approximately three inches deep. 3. [...]