Grants Wellness & Rehabilitation LLC

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #1) of 1 (R #1) resident reviewed for MDS accuracy. This deficient practice is likely to result in a failure to provide adequate care and treatment of the residents' needs.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the appropriate treatment and services related to a Foley catheter (indwelling catheter; a thin, flexible tube inserted into the bladder to drain urine) for 1 (R #1) of 1 (R #1) resident, when staff failed to: Maintain free urine flow through a Foley catheter by positioning the catheter collection bag (also called a drainage bag; a device connected to the catheter tubing to collect urine) below the level of the bladder (hollow organ in the human body that collects urine) so urine can flow freely. This deficient practice is likely to increase the risk of infection and compromises the quality of catheter care.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to provide a homelike environment for 5 (R #1, #2, #3, #5, and #8) out of 5 (R #1, #2, #3, #5, and #8) residents reviewed by not: Maintaining comfortable and safe temperature levels for R #1, #2, #3, and #5. Providing R #8 bed linens. If the facility fails to maintain a homelike environment, then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #8) of 1 (R #8) resident reviewed for MDS accuracy. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician-ordered diabetic foot care was provided for 1 (R #8) of 1 (R #8) resident reviewed for foot care. This deficient practice is likely to result in foot related complications, including infection, injury, or worsening foot conditions.

Inspectors wroteBased on record reviews and interview, the facility failed to:Demonstrate its measures to minimize the risk of Legionella (bacteria naturally found in water that can cause a severe type of lung infection called legionnaires' disease when people inhale tiny water droplets containing the bacteria) in the building's water system, when the Water Management Program (WMP) team failed to develop and implement an adequate Legionnaires Water Management Program (LWMP). If the facility does not have a an adequate LWMP, then residents can be at risk of legionellosis (legionnaires' disease and Pontiac fever, a milder flu-like illness). These failures had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to promote care with dignity and respect for 1 (R #33) of 1 (R #33) residents when R #33 was found sitting in the dining room during lunch with an active bleeding wound on his hand, which included blood on his clothing, face, and both hands. This deficient practice is likely to result in residents feeling unimportant to facility staff and an increased risk of infection due to being around other residents in the dining room.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents or their guardians were aware of the medications they received including the reasons, risks, and benefits of each medication for 2 (R #10 and #13) of 3 (R #10, #13 and #44) residents reviewed for unnecessary medications. If residents and/or their guardians are not informed of the risks and benefits of each medication, then they are not able to make informed decisions.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an adequate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 2 (R #10 and #44) of 3 (R #2, #10 and #44) residents reviewed for baseline care plans. If the facility fails to develop and implement an adequate baseline care plan within 48 hours of admission for residents, then staff may lack necessary guidance to provide appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident due to medical care or lack of medical care). R #10A. Record review of R #10's face sheet revealed an admission date of 07/05/25 and included the following diagnoses: - Urinary tract infection (UTI; [...]

Inspectors wroteBased on record review, observations, and interview, the facility failed to ensure the comprehensive care plan was complete for 1 (R #10) of 3 (R #10, #13 and #44) residents reviewed for care plan accuracy. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for residents.

Inspectors wroteBased on observation and interview the facility failed to ensure essential equipment was in safe operating condition by not replacing a broken plastic light covering for a light located directly over the cooking area of the stove. This deficient practice has the potential to affect all 33 residents on the facility census that was provided by the administrator on 07/08/24.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide reasonable accommodations of resident needs for 1 (R #10) of 1 (R #10) resident reviewed for care when the facility failed to ensure that the resident call light was within the resident's reach and signs were in the preferred language (Navajo-Dine). This deficient practice could likely result in the residents' needs not being met, leaving them at risk of accidents and falls.

Inspectors wroteBased on observation and interview, the facility failed to provide a comfortable and home-like environment for all 33 residents (residents were identified by the census provided by the Administrator on 07/08/24) when they failed to clean mice dropping on the floor in multiple areas of the facility. This deficient practice could likely cause residents to feel like they are not living in a comfortable, home-like environment and are not valued.

Inspectors wroteBased on observation and interview, the facility failed to treat residents with respect and dignity for 2 (R #10 and R # 31) of (R #10 and R # 31) residents randomly identified when the staff failed to knock on the resident's bedroom door before they entered the resident's room. This deficient practice could likely result in residents feeling unimportant and not having privacy.

Inspectors wroteBased on observation and interview, the facility failed to maintain infection control practices for 1 (R #31) of 1 (R #31) residents reviewed for catheter care (the practice of properly utilizing a Foley catheter and catheter bag. The Foley catheter is a tube that is inserted into a patient's bladder to remove urine. The catheter bag is where the urine is drained into). This deficient practice could likely result in the resident being susceptible to infection. A. On 07/08/24 at 10:55 am, during an observation, R #31 was resting in bed, with the bed in the lowest position. R #31's urine catheter bag was attached to the bottom rail of his bed. Due to the position of the bed, the catheter bag was resting on the floor. B. On 07/09/24 at 2:10 pm, during an observation, R #31 was resting in bed, with the bed in the lowest position. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to protect 1 (R #1) of 1 (R #1) resident from the potential of elopement (when a resident leaves the facility without the knowledge of the staff) and accidents. If the facility fails to properly supervise residents for elopement, serious injury or death may occur if they leave the facility unannounced.

Inspectors wroteBased on record review and interview, the facility failed to provide a Facility Initiated Report (mandatory self-initiated facility report of an incident) within 24 hours from the date of the incident to the State Survey Agency, for 1 (R #1) of 3 (R #1, R #2, R #3) residents reviewed for incidents. If the facility fails to provide a Facility Initiated Report to the State Agency then the State Agency will be unable to assure residents are safe and have a hazard free environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide quality care for 1 (R #18) of 2 (R #18 and 30) residents reviewed for death, by not monitoring R #18 oxygen saturation levels and ensuring that R #18 had his nasal cannula in place, after a change in condition was identified (needing supplemental oxygen) due to low oxygen saturation measurements the evening before. These deficient practices likely resulted in resident's passing.

Inspectors wroteBased on record review, observation, and interview, the facility failed to: 1. Discard refrigerated food when it met its 7-day shelf life; 2. Date refrigerated food; and 3. Discard dented cans These deficient practices are likely to affect all 30 residents listed on the census provided by the Director of Nursing (DON) on 02/20/23 and could likely lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on observation and interview, the facility failed to follow infection control practices by; 1. Not doffing (removing personal protection equipment) gloves prior to exiting a room that was occupied by a resident on Transmission Based Precautions (infection control practices that help to stop the spread of germs); 2. Not washing or sanitizing hands in-between assisting residents; 3. [...]

Inspectors wroteBased on interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This deficient practice has the potential to effect any of the 30 residents identified on the census provided by the Director of Nursing (DON) on 02/20/23 who might be placed on antibiotics and could result in the inappropriate use of antibiotics that can lead to resistance of multi-drug resistant organisms.

Inspectors wroteBased on interview the facility failed to have a qualified, trained or Certified Infection Preventionist. This deficient practice could likely to affect all 30 residents identified on the census provided by the Director of Nursing (DON) on 02/20/23. This deficient practice could likely result in residents being at greater risk of infectious disease.

Inspectors wroteBased on interview, observation, and record review, the facility failed to meet professional standards of quality for 1 (R #26) of 2 (R #14 and 26) resident reviewed for resident preferences. This deficient practice could likely result in residents not receiving the option and ability they desire to self treat for mild symptoms.

Inspectors wroteBased on record review and interview, the facility failed to measure, stage (staging helps determine what treatment is best) and document appearance of pressure wounds ulcer (areas of damaged skin caused by pressure, shear or friction) for 2 (R #26, 28) of 2 (R #'s 26, and 28) residents reviewed for pressure ulcers. This deficient practice could likely result in nursing staff being unaware if the wound is healing and if the course of treatment is appropriate causing wounds to worsen.

Inspectors wroteBased on record review and interview, the facility failed to document in a manner that would demonstrate the physician's decisions about a resident's course of treatment for 3 (R #'s 14, 18, and 20) of 3 (R #'s 14, 18, and 20) residents reviewed for physician services. This deficient practice could likely result in residents receiving unnecessary medication and/or not receiving the appropriate care to meet the residents needs.

Inspectors wroteBased on record review and interview, the facility failed to provide behavioral health services for 2 (R #14 and R #18) of 2 (R #14 and R #18) residents reviewed for behavioral health and the use of antipsychotic medications. This deficient practice could likely result in residents not receiving person centered care to evaluate, diagnose, and treat signs or symptoms of depression and/or other mental health conditions.

Inspectors wroteBased on record review and interview, the facility failed to maintain a process to monitor resident behavior after prescribing a psychotropic medication (a medication that alters the chemical makeup of the brain and nervous system) to determine effectiveness for 4 (R #8, R #14, R #20 and R #22) of 7 (R #5, R #8, R #14, R #20, R #22, R #24, and R #134) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being administered psychotropic medications they do not need, experience potential unnecessary drug interactions and/or adverse side effects.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the medication error rate did not exceed 5% by performing 2 medication errors out of 20 opportunities for 2 (R #14 and R #83) of 16 (R# 5, 8, 11, 13, 14, 15, 16, 19, 20, 22, 23, 24, 26, 30, 82, 132, and 134) residents reviewed during medication administration. This likely resulted in a medication error rate of 10%. If medications are not administered as ordered, residents are likely to experience an exacerbation [sudden worsening] or lack of relief from symptoms that the medication was ordered to prevent or manage not allowing residents to experience the maximum benefit intended.

Inspectors wroteBased on record review and interview, the facility failed to update a resident's care plan with a focus (problem), goal, or intervention related to behaviors of refusing care and depression for 1 (R #18) of 2 (R #14 and R #18) residents reviewed for activities of daily living. This deficient practice could likely result in residents not receiving personalized care according to their individual and behavioral needs.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain oxygen equipment according to professional standards for 2 (R #18 and R #24) of 3 (R #14, R #18, and R #24) residents reviewed for respiratory care. This deficient practice could likely result in oxygen tubing not being changed according to the date of install or previous replacement and using humidifier bottles without physician instruction. A. Record review of the facility policy Oxygen Administration, Safety, Mask types- R/S [repiratory system], LTC, [Long Term Care] Therapy & Rehab, last reviewed 06/29/22, revealed Disposable equipment [pieces or parts that are intended to use for a short amount of time and may be easily replaced] should be changed weekly or according to manufacturer's instruction and marked with date and initials. Findings for R #24 B. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to document a resident's change in condition for 1 (R #18) of 1 (R #18) residents reviewed for a change in condition. This deficient practice could likely result in a negatively impacted continuum of care by nursing staff. A. Record review of the facility's policy titled Charting and Documentation, last reviewed 01/05/2022, revealed the following: Purpose: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. [...]