Grover C Dils Medical Center SNF

Inspectors wroteBased on observations, record review, interview, and policy review, the facility failed to ensure a person-centered comprehensive care plan was developed for one of four residents (Resident (R) 2) reviewed for oxygen therapy in the sample of 10 residents. By not having or implementing a comprehensive care plan could potentially place the residents at risk for unmet care needs.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure an oxygen (02) concentrator filter was free of dust and heavy buildup of lint for one of one sampled resident (Resident (R) 2) oxygen tubing was dated/labeled and changed for two of ten sampled residents (R2 and R7). This failure had the potential for the residents to have an increased chance of unnecessary respiratory treatments and/or infection.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure Minimum Data Set (MDS) assessments and/or care plans were timely completed and/or transmitted for 8 of 11 months since the last recertification survey on 05/03/2024. The failed practice had the potential to delay care interventions and provide inadequate care and services to residents. A Medicare Recertification Survey was completed for the facility on 05/03/2024. An MDS Submission Report dated 03/27/2025, revised 04/29/2025, documented the following: June 2024: 44.4% of assessments were completed late (4 of 9) 11.1% of care area assessments were completed late (1 of 9) July 2024: 40.0% of assessments were completed late (2 of 5) August 2024: 10.0% of admission assessments were completed late (1 of 10) 10.0% of admission care plans were completed late October 2024: [...]

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure care plans and/or comprehensive assessments, were completed within the required timeframe for 6 of 10 residents (Resident 2, 3, 6, 7, 10, and 11). The failed practice had the potential to delay care interventions and provide inadequate care and services to residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure hot water was available in the kitchen sinks for food preparation, handwashing, and sanitation. The failed practice had the potential to increase the risk of cross contamination, inadequate handwashing, and food borne illness.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to develop and implement a baseline care plan within 48 hours of admission to address pain for 1 of 10 sampled residents (Resident 10) and Oxygen (O2) therapy for 1 of 10 sampled residents (Resident 11). This deficient practice could have led to unmanaged pain, ineffective symptom control, and compromised respiratory status during the early stages of admission.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the signs and symptoms of bleeding or adverse effects for a resident on Warfarin (anticoagulant medication) were consistently monitored, documented, and reported to the physician for 1 of 10 sampled residents (Resident 9). The deficient practice had the potential to result in adverse outcomes, including an increased risk of bleeding or clotting complications and potential harm due to inadequate monitoring, delayed medical intervention, increased hospitalizations, or even life-threatening hemorrhages.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a physician order for the use, care management, and monitoring of a protective seizure helmet were obtained for 1 of 10 sampled residents. The failed practice had the potential to increase risk of injury from falls and delay identification of skin conditions or concerns.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the resident's Oxygen (O2) was monitored and care orders were obtained per policy for 1 of 10 sampled residents (Resident 11). The deficient practice could have the potential to result in inadequate oxygen administration, unrecognized respiratory decline, delayed medical intervention, and compromised resident safety.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure non-pharmacological interventions were consistently implemented, the effectiveness of pain management was monitored and documented, including location, frequency, severity, and duration, and opioid use adverse effects were monitored for 1 of 10 sampled residents (Resident 10). This deficient practice could have led to unresolved pain and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% was obtained during medication pass. There were 31 opportunities observed, which revealed two errors. The medication error rate was 6.45%.

Inspectors wroteBased on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure 7 of 10 sampled residents (Resident (R) 6, R14, R7, R1, R8, R11 and R12) had an accurate Minimum Data Set (MDS) assessment. The deficient practice had the potential for inaccurate assessment and care planning of the resident.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to attempt alternatives to the use of side rails for four of six residents (R) reviewed with side rails (R1, R8, R11, and R12). This failure had the potential to create a safety hazard for any resident using side rails in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure wheelchair armrest coverings were intact for 2 of 10 sampled residents (Resident 1 and Resident 11). The deficient practice had the potential to create areas that could be injurious to a resident's skin and a non-cleanable surface which could harbor bacteria that could infect any such injury.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure 1 of 10 sampled residents (Resident 12) was provided with a written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. The deficient practice had the potential to affect the resident and their representative by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on observation, interview, policy review, and review Centers for Disease Control (CDC) website, the facility failed to ensure one of one expired insulin vial and two of two undated, opened vials of Mantoux tuberculin purified protein derivative (PPD) were not available for residents' use.

Inspectors wroteBased on document review and interview, the facility failed to ensure the daily nurse staff posting included the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for long-term resident care per shift. This deficient practice had the potential to affect all 13 of 13 residents and visitors of the facility.

Inspectors wroteBased on interview, review of the payroll-based journal (PBJ) submitted to the Centers for Medicare and Medicaid (CMS), the facility failed to ensure one quarter (third quarter of fiscal year 2023) out of three quarters reviewed for PBJ that the direct care staffing information was submitted accurately to CMS. This failure had the potential for staffing issues related to Registered Nurse (RN) coverage for eight consecutive hours per day.