Mary Gran Nursing Center

Inspectors wroteBased on record review and staff, Medical Director #1, Cardiologist, LifeVest Resident Representative and LifeVest Technician interviews, the facility failed to consult with Medical Director #1 when Resident #119's LifeVest (an external defibrillator designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm) delivered treatment shocks to her multiple times in the early morning hours on [DATE]. The LifeVest Resident Representative contacted Resident #119's Cardiologist on [DATE] about Resident #119's severe episodes of ventricular tachycardia, a life-threatening rapid heart rate. The Cardiologist called the facility and requested to talk to the Medical Director. The Cardiologist recommended that the resident be sent to the hospital for evaluation. [...]

Inspectors wroteBased on record review and staff, LifeVest Technician, LifeVest Resident Representative, Medical Director #1 and Cardiologist interviews, the facility failed to protect Resident #119's right to be free from neglect. Resident #119 was admitted on [DATE] with a LifeVest (a wearable device designed to detect life-threatening rapid heart rhythm and, if needed, automatically deliver a treatment shock to restore normal heart rhythm). The nurses and nurse aides had no training on how to care for and manage a resident who required a LifeVest and staff neglected to provide necessary care and services after the LifeVest delivered several treatment shocks. [...]

Inspectors wroteBased on record review and staff, Medical Director #1, Cardiologist, LifeVest technician and LifeVest patient representative interviews, the facility failed to obtain physician directives for staff about what to do when the LifeVest delivered a shock, identify the seriousness of Resident #119's cardiac status and the need for a comprehensive medical evaluation when a LifeVest (an external defibrillator device designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm) shocked the resident multiple times in the early morning hours (beginning shortly after midnight) of 2/11/25. Nurse #1 observed the device deliver shocks to the resident and took no action with the exception of notifying the oncoming first shift nurse that the LifeVest was shocking the resident all through the night. [...]

Inspectors wroteBased on record review and staff, Medical Director #1, Cardiologist, Resident Representative, LifeVest technician, and LifeVest patient representative interviews, the facility failed to ensure staff were trained and competent to care for a resident who wore a LifeVest (a device designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm). Resident #119 received a treatment shock multiple times by the LifeVest she was wearing in the early morning hours (beginning shortly after midnight) on [DATE]. Nurse #1, an agency nurse assigned to Resident #119, observed the device deliver the treatment shocks to Resident #119 and took no action with the exception of notifying the oncoming first shift nurse (Nurse #5) that the LifeVest was shocking the resident all through the night. [...]

Inspectors wroteBased on record review, and resident, staff, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to lock the left brake on Resident #3's wheelchair during a one person stand-pivot transfer on 3/14/25. The left wheelchair brake mechanism was worn and did not engage with the rubber on the tire. The resident could not stand independently or stop the wheelchair when it started to roll. Nurse Aide (NA) #1 lowered Resident #3 to the floor. Both Resident #3 and NA#1 heard a pop. Nurse #3 assessed Resident #3 who denied pain and wanted to go to a scheduled dialysis appointment. During the dialysis appointment, Resident #3 experienced left knee pain. A portable x-ray taken at the facility was negative. Resident #3 continued to have pain and was sent to an orthopedic clinic where he had another x-ray with a negative result. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to: a) label and date opened packages of food for 1 of 1 walk in freezers, b) label and date items in the large walk-in refrigerator and a smaller refrigerator for 2 of 2 refrigerators in the kitchen and c) discard expired items in 2 of 2 refrigerators in 2 of 2 nutrition rooms. This deficient practice had the potential to affect the food served to the residents.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to maintain a residents dignity when Nurse Aide #3 placed a meal tray at the bedside of a cognitively impaired resident (Resident #52) who was dependent on staff for feeding assistance and walked away. Nurse Aide #3 did not return to feed Resident #52 for 40 minutes. Nurse Aide #3 then attempted to feed Resident #52 the cold food on the meal tray. This occurred for 1 of 3 residents reviewed for dignity. A reasonable person may feel helpless, forgotten, and become frustrated at not being able to get assistance to eat their meal.

Inspectors wroteBased on manufacturer directions, observations, and staff interviews, the facility failed to remove 1 opened multi-dose insulin injector pen that was expired in 1 of 3 medication carts (200-hall medication cart), reviewed for medication storage and labeling.

Inspectors wroteBased on record review, and staff, Physician, Nurse Practitioner, and the Consultant Pharmacist interviews the facility failed to 1.) hold Humulin Regular (short acting) insulin when Resident #7's the blood glucose was less than 150 mg/dl (milligrams per deciliter) at 7:30 AM and less than 120 mg/dl at 11:00 AM and 5:00 PM. 2.) hold Resident #8's Humalog (insulin lispro) short acting insulin 5 units before meals for a blood glucose less than 100 mg/dl. 3.) give Resident #9 Humalog insulin 5 units before meals for premeal blood glucose over 150 mg/dl. 4.) give Resident #10 an additional 4 units of Humalog insulin for premeal blood glucose over 200 mg/dl. 5.) hold Humalog insulin according to the physician's order for Resident #11 and Resident#12 when the blood glucose was less than 120 mg/dl. [...]

Inspectors wroteBased on observation and staff interviews the facility failed to maintain sanitizing solutions used in the kitchen at the strength recommended by the manufacturer and failed to repair peeling paint hanging from the ceiling above 2 of 2 food preparation tables. These practices had the potential to affect 90 of 91 residents' food quality and kitchen sanitation safety.

Inspectors wroteBased on observations, record review, resident, staff, and the Nurse Practitioner's interviews the facility failed to implement an order for Metoprolol 50 milligrams daily (a beta blocker indicated for the treatment of hypertension and heart failure) that was prescribed for atrial fibrillation (irregular heart rhythm) following a cardiology appointment. The medication error resulted in 25 missed doses. This occurred for 1 of 1 resident (Resident #55) reviewed for medication administration.

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to provide an ongoing resident centered activities program based on residents' individual interests for 2 of 7 residents reviewed for activities (Resident #27 and Resident #50).

Inspectors wroteBased on record review, staff and Consultant Pharmacist interviews, the facility failed to address drug irregularities noted by the Consultant Pharmacist on two consecutive monthly Medication Regimen Reviews for 2 of 5 residents (Resident #43 and Resident #5) reviewed for unnecessary medications.

Inspectors wroteBased on record review, staff, Nurse Practitioner and Consultant Pharmacist interviews, the facility failed to 1). accurately transcribe and administer a medication used to treat anxiety resulting in resident was administered antianxiety medication on a scheduled basis instead of as needed per the physician order, and 2) accurately transcribe and administer a medication used to treat depression and insomnia resulting in resident received 22 doses of the medication at a higher dose than ordered for 2 of 5 residents (Resident #43 and Resident #5 ) reviewed for psychotropic medication (a medication used to treat behavior, mood, thoughts, or perception).

Inspectors wroteBased on record review, staff, Nurse Practitioner and Consultant Pharmacist interviews, the facility failed to follow parameters for administration of a medication used to treat hyperglycemia resulting in 16 doses administered in error for 1 of 1 resident (Resident #5) reviewed for medication error.

Inspectors wroteBased on observations, record review, staff, and resident interviews the facility failed to provide an adaptive handled cup for 1 of 1 resident (Resident #27) reviewed for accommodation of needs.

Inspectors wroteBased on observations and staff interviews the facility failed to maintain potentially hazardous food items within safe temperature range for cold food items, at or below 41 degrees Fahrenheit (F) during the lunch meal service.

Inspectors wroteBased on observation, record review, staff, and Physician interviews the facility failed to notify the physician when a resident was noted to have redness and bleeding along the gumline for 1 of 1 resident reviewed for dental care (Resident #65).

Inspectors wroteBased on record review, observation and staff interview, the facility failed to shave a resident who was dependent on the staff for activities of daily living (ADL) care for 1 of 1 sampled resident reviewed for ADLs (Resident #65).

Inspectors wroteBased on record review, staff and Nurse Practitioner interviews the facility failed to obtain physician ordered laboratory tests for 1 of 3 residents reviewed for antibiotic use (Resident # 44).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to obtain physician ordered weights for 2 of 2 residents (Resident # 39, Resident #44) reviewed for nutrition.

Inspectors wroteBased on observation, record review, resident, staff, and Physician interviews the facility failed to obtain dental care for a resident with painful inflamed upper gums, and strong mouth odor for 1 of 1 resident reviewed for dental (Resident #65).

Inspectors wroteBased on record review, administrative staff, and resident interview the facility failed to explain the arbitration agreement, including the right to rescind the agreement within 30 days, prior to having the resident or responsible party sign the agreement for 2 of 3 residents (Resident #83 and Resident #88).

Inspectors wroteBased on a record review, administrative staff, and resident interview the facility failed to provide an arbitration agreement that provided for 1). a selection of a neutral arbitrator agreed upon by both parties and 2). selection of a venue that was convenient to both parties for 3 of 3 residents reviewed for arbitration (Resident #294, Resident #83, and Resident #88).

Inspectors wroteBased on observations, record review and staff interviews, the facility's Quality Assurance & Performance Improvement Program (QAPI) failed to maintain implemented procedures and monitor interventions that the committee put into place following a recertification and complaint survey on 02/17/22. This was for 2 repeat deficiencies that were originally cited in the areas of notification and nutrition and were subsequently recited on the current recertification and complaint survey on 03/23/23. The continued failure during 2 surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement their infection control policy for Contact Precautions when 2 of 2 staff members (Nurse #2 and Nurse Aide #1) failed to don gloves and gown prior to entering 2 of 2 resident rooms (Resident #39, Resident #4) who were on Contact and Enteric Precautions.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to document accurate information on the daily nurse staffing sheets for 4 of 4 days (03/20/23, 03/21/23, 03/22/23, and 03/23/23) of the survey.