Grande Pointe Healthcare Commu

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, review of the facility's investigation, and facility policy review, the facility failed to provide adequate supervision to ensure a resident with moderately impaired cognition did not leave the facility without staff awareness. This affected one resident (#102) of three residents reviewed for elopements. The facility census was 162.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a physician order for a pressure ulcer treatment was transcribed into the electronic medical records. This affected one resident (#136) of three residents reviewed for physician orders. The facility census was 151.

Inspectors wroteBased on observation and interview, the facility failed to ensure appropriate infection control techniques were used during incontinence care. This affected one resident (#136) of two residents observed for incontinence care. The facility census was 151.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to complete wound treatments as ordered by the physician. This affected one resident (#114) of three residents reviewed for wound care. The facility census was 140.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to timely implement physician orders to insert an indwelling urinary catheter. This affected one resident (#145) of three residents reviewed for urinary tract infection (UTI) prevention. The facility census was 140.

Inspectors wroteBased on observation, interview, and review of the facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents except three residents (#68, #75, and #207) who received nothing by mouth and did not receive food from the facility's kitchen. The facility census was 147.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure adequate supervision to prevent accidents related to smoking safety. This had the potential to affect four residents (#62, #85, #98, and #210) of four residents reviewed for smoking. The facility identified 18 current residents who smoked. The facility census was 147.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure residents with a diagnosis of Post-Traumatic Stress Disorder (PTSD) were provided culturally competent and trauma-informed care. This affected two residents (#81 and #82) of two residents reviewed for PTSD. The facility census was 147.

Inspectors wroteBased on observation, record review, self-reported incident (SRI) review, review of a police report, facility policy review and interviews, the facility failed to ensure Resident #28, who had dementia, was deemed incompetent, and unable to provide consent, was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for actual physical and psychosocial harm on 11/26/24 at approximately 8:20 P.M. when Resident #18, who had a history of engaging in physical activity (i.e. hand holding and touching behaviors) with Resident #28 without care planned interventions, was observed by Certified Nurse Aide (CNA) #396 engaged in an activity indicative of oral sex on Resident #28. This affected one resident (#28) of three residents reviewed for abuse. The facility census was 158. [...]

Inspectors wroteBased on personnel file review, interview, review of facility policies and review of the Ohio Revised Code (ORC), the facility failed to hire staff free of disqualifying offenses. This affected one out of seven personnel files reviewed and had the potential to affect all 158 residents residing in the facility.

Inspectors wroteBased on personnel record review, facility policy review, and interview, the facility failed to implement their abuse policy and procedure regarding checking potential applicants against the Ohio Nurse Aide Registry (NAR) prior to working with residents as well as completing background checks as required. This affected six out of seven personnel files reviewed and had the potential to affect all 158 residents who resided in the facility.

Inspectors wroteBased on record review, review of the facility assessment, self-reported incident (SRI) review and interview the facility failed to maintain sufficient levels of staff on the secured care unit to meet the supervisory needs of all residents. This affected two residents (#18 and #28) and had the potential to affect the 41 residents residing on the facility's secured memory care unit. Facility census was 158.

Inspectors wroteBased on record review, review of a self-reported incident (SRI), review of facility policies and interview, the facility failed to timely inform residents' attending physicians of an instance of resident-to-resident sexual abuse. This affected two residents (Resident #18 and Resident #28) out of three residents reviewed for abuse. Facility census was 158.

Inspectors wroteBased on interview, review of a self-reported incident (SRI), review of the facility investigation and review of the facility policy, the facility failed to thoroughly investigate allegations of resident-to-resident sexual abuse. This affected one resident (#28) of three residents reviewed for abuse. Facility census was 158.

Inspectors wroteBased on record review, fall investigation review, interview and review of the facility policy, the facility failed to thoroughly investigate falls to ensure appropriate safety interventions were in place for Resident #160. This affected one resident (#160) of three residents reviewed for falls. Facility census was 158.

Inspectors wroteBased on closed medical record review, review of skin and wound notes, facility policy review and interview, the facility failed to ensure individualized care planned interventions were developed and followed to prevent Resident #165 from developing in-house pressure ulcers within 30 days of admission and failed to ensure the pressure ulcer was properly treated, and interventions were initiated to promote healing and to prevent Resident #165 from developing an additional full thickness wound to the left buttock from incontinence associated dermatitis. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #28 and Resident#127 were provided incontinence care timely. This affected two residents (Resident's #28 and #127) out of four residents reviewed for incontinence care. The facility census was 160.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure a medication error rate of less than 5 percent (%). A Total of two errors out of 26 opportunities were observed resulting in a 7.69% medication error rate. This affected two residents (Resident's #98 and #139) out of six residents reviewed for medication administration. The facility census was 160.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, review of a facility self-reported incident (SRI) investigation, observation, staff and resident interviews, and review of the facility Abuse, Neglect and Misappropriation policy, the facility failed to ensure controlled substances were stored and discarded properly to prevent misappropriation. This affected seven residents (#256, #257, #258, #259, #260, #261, and #262) of seven residents reviewed for misappropriation. The facility census was 156.

Inspectors wroteBased on record review, review of facility policy and interview the facility failed to develop and implement a comprehensive and effective pain management program for Resident #156, including a comprehensive pain assessment and effective interventions to timely treat the resident's pain. This affected one resident (#156) of three residents reviewed for pain. The facility census was 154. [...]

Inspectors wroteBased on record review, interview, and review of the facility policy the facility failed to ensure care planned interventions were timely implemented for treatments for Resident #156's unstageable sacral pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). This affected one resident (#156) out of three residents reviewed for wounds. The facility census was 154.

Inspectors wroteBased on interview, record review, and review of the facility policy the facility failed to ensure Resident #156 had individualized care planned interventions for falls, failed to ensure a thorough investigation and accurate follow up evaluation after a fall. This affected one resident (#156) out of three residents reviewed for accidents. The facility census was 154.

Inspectors wroteBased on interview, record review, and review of the facility policy the facility failed to ensure Resident #156 received dialysis on his scheduled days per physician orders. This affected one resident (#156) out of three residents reviewed for dialysis. The facility census was 154.

Inspectors wroteBased on interview, record review, and review of the facility policy the facility failed to ensure Resident #156 received medications per physician orders. This affected one resident (#156) out of three residents reviewed for medication administration. The facility census was 154.

Inspectors wroteBased on interview, observation, record review, and review of facility policy the facility did not ensure Resident #131 was provided timely incontinence care. This affected one resident (#131) out of three residents reviewed for incontinence. This had the potential to affect 102 residents (#2, #3, #4, #5, #7, #11, #12, #13, #14, #15, #17, #19, #20, #22, #23, #25, #26, #27, #28, #29, #30, #32, #33, #36, #37, #38, #39, #40, #41, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #57, #59, #62, #64, #65, #66, #68, #70, #71, #72, #73, #74, #76, #77, #79, #80, #81, #82, #83, #84, #86, #87, #88, #91, #92, #93, #96, #97, #103, #104, #105, #107, #108, #110, #112, #114, #115, #117, #118, #119, #120, #121, #123, #125, #126, #127, #128, #131, #132, #133, #134, #135, #136, #137, #138, #139, #140, #142, #144, #145, #146, and #148) that were identified by the facility as incontinent. [...]

Inspectors wroteBased on record review, interview, and observation the facility failed to provide residents who received meals in their rooms the opportunity to choose menu items prior to meal service and failed to ensure a copy of the menus and the always available meal alternatives were posted in an easily accessible location. This affected two (Resident's #16 and #67) of five residents reviews for choices. The facility census was 156.

Inspectors wroteBased on record review, observations, and interviews the facility failed to change dirty bed linens in a timely manner. This affected one (Resident #22) of five residents reviewed for environment. The facility census was 156.

Inspectors wroteBased on record review, observations, and interviews the facility failed to provide activities for Resident #104. This affected one (Resident #104) of five residents reviewed for activities. The facility census was 156.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate feeding assistance. This affected one resident (Resident #356) of one resident observed for feeding assistance. The facility census was 156.

Inspectors wroteBased on interview and record review the facility failed to provide appropriate dialysis care. This affected three (Resident's #25, #131, #135) of three reviewed for dialysis care. The facility census was 156.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper sanitation procedures of resident unit pantries. This had the potential to effect 162 of 171 residents who ate by mouth. Nine Residents (#1, #4, #16, #24, #67, #86, #109, #116 and #464) received enteral nutrition.

Inspectors wroteBased on observation, interview, record review, and policy and procedure review, the facility failed to identify and provide needed care and resident centered services, in accordance with the professional standards of practice to meet the needs of Residents #1 and #43. This affected one (Resident #1) of one resident reviewed for position/mobility and one (Resident #43) of three residents reviewed for activities of daily living.

Inspectors wroteBased on record review and interview the facility failed to notify the long-term care ombudsman of resident transfers to the hospital within 30 days. This affected four of four residents (Residents #11, #44, #107, and #129) reviewed for transfer and discharge.