Grant Healthcare and Rehabilitation

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to prepare and serve food in a safe manner. Observations on 09/09/2025 during lunch tray line preparation staff failed to utilize proper hand hygiene.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and to implement interventions to protect the residents. The facility failed to follow their policy related to ensuring the ice machines and water fountain were properly cleaned. Additionally, the facility failed to ensure Resident (R) 9's catheter was properly secured, and the catheter bag remained off the floor to help prevent infection.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to keep residents free from abuse for 1 of 25 sampled residents (Resident (R) 341). On [DATE], R341 was physically restrained by Certified Nursing Assistant (CNA) 6 and Licensed Practical Nurse (LPN) 6 while they were providing care which resulted in bruising of both of the resident's forearms.

Inspectors wroteBased on observation, interview, review of the website https://www.fda.gov/media/74866/download, review of Medication Refrigerator Temperature Guidelines: What You Should Know, and review of the facility's policies, the facility failed to label and store drugs and biologicals in accordance with currently accepted professional principles for 1 of 2 medication refrigerators observed. A multi-use vial of Tuberculin Purified Protein Derivative (PPD) was found in a plastic bag in the door of the refrigerator and was opened and not dated in the Medication Room on Heritage Hall.

Inspectors wroteBased on observation, interview, review of the facility's policies, review of the manufacturer's directions for use for the Assure Prism Multi-Blood Glucose Monitoring System, and review of the instructions for Clorox Healthcare Bleach Germicidal Wipes, the facility failed to follow standard infection procedures for cleaning and handling 1 of 8 glucometers.

Inspectors wroteBased on observation, interview, and review of facility Policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observation on 07/30/19 at 11:40 AM, revealed food on the steam table was uncovered from 11:40 AM until 12:07 PM, a total of twenty-seven (27) minutes prior to food being served from tray line. In addition, observation on 07/31/19 at 11:40 AM, revealed food on the steam table was uncovered from 11:40 AM until 12:00 PM, a total of twenty (20) minutes, prior to food being served from tray line. Furthermore, observation of a test tray on 07/31/19 at 1:01 PM, revealed milk and juice temperatures were measured at fifty-two (52) degrees Fahrenheit (F), and tuna fish on the test tray was measured at sixty (60) degrees F, indicating cold foods did not hold temperature.

Inspectors wroteBased on interview, record review, and review of the facility's Policy, it was determined the facility failed to implement written policies related to reporting and investigating allegations of abuse. This affected two (2) of eighteen (18) sampled residents (Residents #81 and #31). There was no documented evidence the facility implemented their written abuse policies related to completing a thorough investigation after staff witnessed a resident-to-resident verbal altercation which lead to Resident #81 grabbing a butter knife and threatening to stab Resident #31 on 04/22/19. In addition, there was no documented evidence the facility implemented their written abuse polices related to reporting the alleged violation to State Agencies. (Refer to F-609 and F-610)

Inspectors wroteBased on interview, record review, and review of the facility's Policy, it was determined the facility failed to ensure all alleged violations involving abuse are reported immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse, to the Administrator and to State Agencies for two (2) of eighteen (18) sampled residents (Residents #81 and Resident #31). On 07/30/19 at 12:56 PM, Resident #31 reported during an interview with the State Agency (SA) Representative, Resident #81 pulled a knife on him/her a few months ago. Review of Resident #81 Progress Notes, dated 04/22/19, revealed Resident #81 cussed a resident and subsequently picked up a knife off the table and stated he/she would stab the other resident. Staff interviews verified the allegation; [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to have evidence that all alleged violations of abuse are thoroughly investigated. This affected two (2) of eighteen (18) sampled residents (Residents #81 and #31). Staff interviews revealed on 04/22/19, Resident #81 was involved in a resident-to-resident verbal altercation with Resident #31 that escalated resulting in Resident #81 grabbing a butter knife from the table and threatening to stab Resident #31. However, there was no documented evidence of an investigation related to this incident.

Inspectors wroteBased on interview, record review, and review of facility Policy, it was determined the facility failed to notify the Resident or the Resident's Representative of the transfer/discharge and the reasons for the transfer in writing, for two (2) of eighteen (18) sampled residents (Resident # 36 and Resident #39). Resident #36 was transferred to an acute care hospital, on 05/28/19 with return anticipated; however, there was no documented evidence Resident #36 or his/her Resident Representative received a written notice of transfer/discharge. Additionally, Resident #39 was transferred to an acute care hospital, on 05/18/19 with return anticipated; however, there was no documented evidence Resident #39 or his/her Resident Representative received a written notice of transfer/discharge.

Inspectors wroteBased on interview, record review, and review of the facility's Policy, it was determined the facility failed to provide written information to the Resident or the Resident Representative related to the Bed-hold Policy at the time of transfer for one (1) of eighteen (18) sampled residents (Resident #39). The facility obtained a Provider's Order to transfer Resident #39 to an acute care facility for evaluation following a change in condition on 05/18/19; however, there was no documented evidence the facility provided the Resident or the Resident's Representative written information related to the facility's Bed-hold Policy related to this transfer.

Inspectors wroteBased on interview, record review, and review of facility Policy, it was determined the facility failed to develop and implement the Comprehensive Care Plan (CCP) to address the resident's needs for one (1) of eighteen (18) sampled residents (Residents # 63). Resident #63 sustained a fall on 06/19/19, and the facility implemented a tab alarm to the resident's wheelchair as a fall prevention intervention. However, there was no documented evidence the CCP was developed and implemented with an intervention for ongoing re-assessment of the effectiveness of the tab alarm device with necessary modification as necessary. In addition, Resident #63 sustained a fall on 06/27/19. Per the Investigation, the facility determined the Root Cause Analysis (RCA) of the fall event was excess fluid removed during dialysis. [...]

Inspectors wroteBased on interview, record review, and review of the facility Policies, it was determined the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for one (1) of four (4) sampled residents reviewed for falls out of a total sample of eighteen (18) residents (Resident #63). Resident #63 was assessed by the facility to be a Fall Risk, per the admission Assessment, dated 06/10/19. The facility implemented a tab alarm to the resident's wheelchair as a fall intervention, on 06/19/19 after a fall accident/incident. [...]