Grundy Care Center

Inspectors wroteBased on interviews, schedule review and CMS (Centers for Medicare and Medicaid Services) document submission review, the facility failed to submit accurate licensed nurse coverage hours into the CMS system, resulting in the appearance of low weekend staffing and lack of 24 hour licensed coverage. The facility reported a census of 30 residents.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to safely handle food while preparing a sandwich. The staff put on gloves then touched other items with their gloved hands prior to touching bread with the same gloved hands. The facility reported a census of 30 residents.

Inspectors wroteBased on clinical record review, policy review, video footage review and staff interviews, the facility failed to prevent a resident deemed as high risk for elopement exit the building without supervision for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 27 residents.

Inspectors wroteBased on observations, clinical record reviews, facility policy review, resident, and staff interviews, the facility failed to protect a resident from physical and mental abuse for 1 of 3 residents reviewed (Resident #1). Staff A, Certified Nurse Aide (CNA), accepted money, kissed, sent inappropriate pictures via text, and exchanged inappropriate touch with Resident #1. The inappropriate interactions continued until Staff A resigned from the facility. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 10/16/24 on 1/6/25 at 2:55 PM The facility staff removed the Immediate Jeopardy on 1/7/25 by implementing the following actions: a. Resident #1 saw psychiatry on 11/14/24 (prior to self-report), then again on 12/12/24, and is scheduled to see psychiatry again on 1/9/25. [...]

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to provide licensed nurse coverage 24 hours a day 7 days a week. Review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 3 2024 (April 1 through June 30) revealed the facility failed to provide licensed nurse coverage 24 hours per day on 5/7/24, 5/11/24, 5/13/24, 5/19/24, 6/15/24, 6/29/24, and 6/30/24.

Inspectors wroteBased on staff interview, resident interview, policy review, Facility Assessment and Payroll Based Journal (PBJ) review the facility failed to ensure appropriate staffing, lacked Registered Nursing (RN) coverage and lacked a Director of Nursing (DON) on four days. The facility reported as census of 26 residents.

Inspectors wroteBased on record review, facility provided document, staff interview, and policy review the facility failed to notify a Resident's Representative and the Long Term Care Ombudsman of discharge/transfer of residents as required for 2 of 4 residents reviewed who were discharged /transferred from the facility (Residents #3, #20). The facility reported a census of 26 residents.

Inspectors wroteBased on staff interview, clinical record review and policy, the facility failed to submit for an updated Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 resident reviewed with a new mental health diagnosis (Resident #7). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, record review, staff interview, and policy review the facility failed to follow professional standards regarding following facility policy, following physician's orders, and failing to notify physician for 2 of 12 residents reviewed (Residents #3 and #23). The facility reported a census of 26 residents.

Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to ensure repositioning for 2 of 3 residents reviewed for positioning and skin care (Residents #4 & #20). The facility reported a census of 26 residents.

Inspectors wroteBased on staff interview, resident interview, clinical record review, observations, and policy review the facility failed to provide appropriate interventions to minimize or prevent complications of infections for 1 of 2 residents reviewed for urinary conditions (Residents #10). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure the medication and treatment cart remained locked in a resident care area when not under staff supervision. The facility reported a census of 26 residents.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to store food in accordance with professional standards for food service safety. The facility reported a census of 26 residents.

Inspectors wroteBased on record review, observation, and staff interviews the facility failed to effectively and efficiently maintain the highest well-being of each resident. The facility failed to sustain their Plan of Correction (POC) dated 9/12/23, to ensure required members were present at the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. The facility reported a census of 26 residents.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to have the required members present at their Quality Assurance and Performance Improvement (QAPI) meetings. The facility did not have the Director of Nursing (DON) or the Infection Preventionist (IP) in attendance at all quarterly meetings. The facility reported a census of 26 residents.

Inspectors wroteBased on record review, document review, interviews, and policy review, the facility failed to provide the Bed Hold policy for 1 of 2 residents reviewed (Resident #3). On 10/5/24 Resident #3 was admitted to the hospital, a Bed Hold policy was not discussed/given to Resident #3 or their representative. The facility reported a census of 26 Residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accurately document pressure ulcers for 1 of 3 residents reviewed (Resident #1). During the record review of Resident #1's record, the assessments revealed inconsistent documentation related to their wound on their right buttock. As the wound declined, the facility failed to update the stages of the pressure ulcer with worsening changes. The facility reported a census of 27 residents.

Inspectors wroteBased on observation, document review and staff interview, the facility failed to ensure licensed nurse coverage 24 hours a day. On 6/15/24 the night nurse clocked out at 6:45 AM and the day nurse clocked in at 8:41 AM The facility did not have a licensed nurse on duty, in house during that time frame. The facility staff contacted the Director of Nursing (DON) and the Administrator who failed to act to immediately to provide licensed coverage. The facility identified 15 diabetic residents, 8 of whom are insulin dependent with one resident (Resident #7) who had a blood glucose reading of 65, during the time the facility didn't have no licensed nurse coverage. In addition, the facility had one resident (Resident #2) had a tracheostomy that required suctioning three times a day (TID) and as needed. The facility identified a census of 28 residents.

Inspectors wroteBased on observations, document review, menu review, and staff interview the facility failed to follow the planned menu for residents on all diet types. The facility identified a census of 28 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to protect food from contamination during meal service. The facility reported a census of 28 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to employ sufficient staff with the appropriate competencies to carry out the functions of the food and nutrition service. The facility employed a corporate Dietitian on a part time consultant basis and designated a person who lacked the required certification and/or experience to serve as the Dietary Supervisor. The facility reported a census of 28 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that residents had the right to be free from abuse, and exploitation for 4 out of 4 residents reviewed (Resident #17, #20, #136 and #187). The facility must not allow verbal, mental, physical or sexual abuse. Resident #18 was found kissing resident #20 and inappropriately touching Resident #136 and Resident #187. All 3 of these residents had diminished cognitive functioning. Resident #18 was found sitting in Resident #17's doorway and would not leave when she asked him to, causing Resident #17 psychosocial harm. These incidents resulted in an immediate jeopardy to residents' health and safety. The facility reported a census of 32. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide adequate supervision for all residents resulting in exploitation for 4 out of 4 residents reviewed (Resident #17, #20, #136, and #187). The facility must not allow verbal, mental, physical or sexual abuse. Resident #18 was found kissing resident #20 and inappropriately touched Residents #136 & #187. These residents had diminished cognitive functioning. Resident #18 was found sitting in Resident #17's doorway and would not leave when she asked him to, causing Resident #17 fear. The facility was aware of these and other incidents but failed to put interventions into place that would prevent Resident #18 from further exploiting female residents. These incidents resulted in an immediate jeopardy to residents' health and safety. The facility reported a census of 32. [...]

Inspectors wroteBased on clinical record review, observation, staff interview, and facility policy review, the facility failed to maintain proper infection control practices to prevent cross contamination and potential infection of residents when providing cares and treatments. The facility reported a census of 32 residents.

Inspectors wroteBased on record review and interview, the facility failed to have accurate code status directives available to their staff for 2 of 16 residents reviewed (Residents #17 and #33). Resident #17 had a Do Not Resuscitate (DNR) directive in the front book and a full code/CPR directive in her electronic record. Resident #33 did not have any code status direction in the book. The facility reported a census of 32 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that residents had the right to be free from abuse, and exploitation for 4 out of 4 residents reviewed (Resident #17, #20, #136, and #187). The facility must not allow verbal, mental, physical or sexual abuse. Resident #18 was found kissing resident #20 and inappropriately touched Residents #136 & #187. These residents had diminished cognitive functioning. Resident #18 was found sitting in Resident #17's doorway and would not leave when she asked him to, causing Resident #17 fear. The facility was aware of these and other incidents but failed to put interventions into place that would prevent Resident #18 from further exploiting female residents. The facility reported a census of 32.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to develop a comprehensive person centered care plan for 3 of 16 residents reviewed (Resident #7, #17, #26). The facility reported a census of 32 residents.

Inspectors wroteBased on observation, record review, staff interviews and manufacturer's insert, the facility failed to provide services that met professional standards regarding medication administration for 1 of 6 residents observed (Resident #16) who did not have their insulin flex pen primed prior to administering insulin (to ensure the proper amount of insulin administered) and did not leave the needle injected in the skin for the recommended period of time to ensure the full dose of medication was given. The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, observations, resident and staff interviews, and policy review, the facility failed to provide interventions specific enough to guide the staff to provide services and treatment for an indwelling catheter with interventions to maintain the resident and catheter cleanliness for 2 of 2 residents reviewed for catheter care (Resident #14 and #28). The facility reported a census of 32 residents. The Minimum Data Set (MDS) dated [DATE] for Resident #14 revealed a diagnosis of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) and identified an indwelling catheter that required the assistance of 1 person to provide care. The Care Plan dated 6/30/23 for Resident #14 failed to address cleaning care for the indwelling catheter. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a sterile field for tracheotomy care for 1 of 1 resident's observed (Resident #29). Staff A, Registered Nurse (RN), performed tracheostomy care on Resident #29 and broke the sterile field when she touched the objects in the sterile tray with her bare hands. The facility reported a census of 32.

Inspectors wroteBased on clinical record review, resident and staff interviews, observation, and policy review, the facility failed to provide pain management for 1 of 3 residents reviewed (Resident #186). The facility failed to pre-medicate Resident #186 before Physical and Occupational Therapy was initiated as per the resident's request and policy directive. The Minimum Data Set (MDS) dated [DATE] for Resident #186 revealed she was admitted to the facility on [DATE] with a diagnosis of post-surgical of a nondisplaced fracture of the left humerus (upper arm), fracture of pelvis and had the ability to express her ideas and wants. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure nursing agency staff received orientation and direction prior to providing care to the residents of the facility. The facility reported a census of 32 residents

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to ensure antipsychotic medications were re-assessed or included a clinical rational to continue the medication for 3 of 5 residents reviewed (Resident 26, #28, #30). The facility reported a census of 32 residents.

Inspectors wroteBased on observation, interview, record review, and manufacturer's package insert review, the facility failed to keep their medication error rate less than 5 percent for 1 of 1 residents (Resident #16) observed. An observation of 25 medications being passed was completed with 2 medication errors noted giving the facility an 8% medication error rate. The facility reported a census of 32 residents. Finding Include: In an observation on 8/9/23 at 7:52 AM, Staff A, RN prepared a Novolog FlexPen by placing a needle on the pen and then dialed it to 5 units and administered the insulin in Resident #16's right lower quadrant (RLQ) of her abdomen holding the syringe in the abdomen for no more than a count of 2. Staff A, RN failed to prime the insulin FlexPen with 2 units prior to setting and administering the insulin and failed to leave the FlexPen needle injected under the skin for a count of 6. [...]

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to have the required members present at their quarterly Quality Assurance and Performance Improvement (QAPI) meeting. The facility did not have the Director of Nursing (DON) or the Infection Preventionist (IP) in attendance at the November 29, 2022 quarterly meeting. The facility reported a census of 32 residents.