Grace Manor Care Center

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

A recertification survey was conducted from 4/9/24 to 4/11/24. Two deficiencies were cited. An Emergency Preparedness survey was conducted from 4/9/24 to 4/11/24. No deficiencies were cited. Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly in two of two medication carts and one of one medication rooms.Specifically the facility failed to:-Ensure medications were not loose in medication carts; and,-Ensure expired medications were not stored with current medications in the medication storage room.Findings include:I. Facility policy and procedureThe Storage of Medications policy and procedure, revised November 2020, was received from the director of nursing (DON) on 4/10/24 at 2:40 p.m. It documented in pertinent part, "The facility stores all drugs and biologics in a safe, secure, and orderly manner."Drugs and biologicals are stored in packaging, containers or other dispensing systems in which they were received."Nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner."Discontinued, outdated, or deteriorated drugs and biologicals are returned to the dispensing ph.. Based on observations, record review and interviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#19) of 12 residents out of 15 sample residents.Specifically, the facility failed to have a wound care order in place prior to treatment being provided for Resident #19.Findings include:I. Facility policy and procedureThe Care of Skin Tears, Abrasions and Minor Breaks policy, revised September 2013, was provided by the director of nursing (DON) on 4/10/24 at 2:31 p.m. It read in pertinent part, "The purpose of the procedure was to guide the prevention and treatment of abrasions, skin tears and minor breaks in the skin. An abrasion is an area of the skin that has been damaged by friction, scraping, rubbing or trauma. "Preparation:-Obtain a physician' s order as needed;-Check the treatment record; and,-Generate a non-pressure form and complete it."II. Resident #19A. Resident statusResident #19, age above 65, was admitted on 1..

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/15/2024 and 01/21/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A complaint survey, prompted by #CO31623 was conducted on 4/17/23-4/19/23. One deficiency was cited. Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents received adequate supervision to prevent an accident/hazard. Resident #1, who had a diagnosis of neurocognitive disorder with Lewy bodies (type of progressive dementia that leads to a decline in thinking, reasoning and independent function), was admitted to the facility on 3/7/22. The facility failed to follow standards of practice in providing incontinence care by not having all supplies ready and letting go of the resident after helping the resident into the sitting position on the edge of bed. The facility failed to timely implement appropriate interventions, including assistance with all activities of daily living (ADL) as documented in his quarterly 1/6/23 minimum data set (MDS) assessment. The facility failed to provide and implement two person bed mobility/toileting and dressing assistance and failed to consistently provide two person bed mobility/toileting and dressing assistance after the fall according to record review, interviews and in accordance with the post fall intervention and education provided by the director of nursing (DON). Due to the facility' s failures, and the staff' s failure to take proper and reasonable care when providing bed mobility/toileting and dressing assistance resulted in the resident falling from seated on the edge of bed to the floor landing on his head, neck, and shoulder. It resulted in the resident sustaining injuries of a head injury, scalp hematoma (bleeding on brain), facial bruising, cervical spine strain, and right shoulder contusion. His pain went from a baseline of 0 out of 10 (on a pain scale with 10 being the worst pain) to 8 out of 10 resulting in a decrease in functional ability and he required evaluation and treatment at the emergency department (ED).Findings include:I. Facility policy and procedureThe Falls and Fall Risk, Managing policy and procedure, revised March 2018, was provided by the DON on 4/18/23 at 10:41 a.m. It read in pertinent part, "Ba..

A survey prompted by complaint #CO31911 was completed 4/17/23 to 4/19/23. One deficiency was cited. Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents received adequate supervision to prevent an accident/hazard. Resident #1, who had a diagnosis of neurocognitive disorder with Lewy bodies (type of progressive dementia that leads to a decline in thinking, reasoning and independent function), was admitted to the facility on 3/7/22. The facility failed to follow standards of practice in providing incontinence care by not having all supplies ready and letting go of the resident after helping the resident into the sitting position on the edge of bed. The facility failed to timely implement appropriate interventions, including assistance with all activities of daily living (ADL) as documented in his quarterly 1/6/23 facility assessment. The facility failed to provide and implement two person bed mobility/toileting and dressing assistance and failed to consistently provide two person bed mobility/toileting and dressing assistance after the fall according to record review, interviews and in accordance with the post fall intervention and education provided by the director of nursing (DON). Due to the facility' s failures, and the staff' s failure to take proper and reasonable care when providing bed mobility/toileting and dressing assistance resulted in the resident falling from seated on the edge of bed to the floor landing on his head, neck, and shoulder. It resulted in the resident sustaining injuries of a head injury, scalp hematoma (bleeding on brain), facial bruising, cervical spine strain, and right shoulder contusion. His pain went from a baseline of 0 out of 10 (on a pain scale with 10 being the worst pain) to 8 out of 10 resulting in a decrease in functional ability and he required evaluation and treatment at the emergency department (ED).Findings include:I. Facility policy and procedureThe Falls and Fall Risk, Managing policy and procedure, revised March 2018, was provided by the DON on 4/18/23 at 10:41 a.m. It read in pertinent part, "Based on previous evaluati..