Grace Pointe Cont Care Sr Campus, Skilled Nursing

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

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.

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.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

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.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

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

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:1. Ceiling tile in Rehab Gym has large hole around the fire sprinkler head. NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.The smoke barrier deficiencies have the potential to affect all residents, visitors, and staff within those smoke compartments.The deficiencies were discussed during the exit conference. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Sections 19.7.1.6 and 4.7.4. This was evidenced by the following: 1. No records or documentation for fire drills for 2nd shift in the second quarter.NFPA 101 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.NFPA 101, 4.7.4. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.This was discussed during the exit conference. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on December 5, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."The facility is two story, Type II (111), construction. The facility was constructed in 2009. and is licensed for 53 beds and the census on the date of the survey was 48. This building is separated from the Assisted Living portion of the building by 2-hour fire rated construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinklered. The results of this survey were discussed with the Facility Administrator and Maintenance Director during the exit conference.

A recertification survey was conducted from 11/13/23 to 11/16/23. Two deficiencies were cited. An Emergency Preparedness survey was conducted from 11/13/23 to 11/16/23. No deficiencies were cited. Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in one of two medication rooms.Specifically, the facility failed to ensure multiple use vials were labeled appropriately.Findings include:I. Manufacturer' s recommendationsAccording to the Aplisol package insert, retrieved on 11/20/23 from: https://www.fda.gov/media/74862/download "Vials in use for more than 30 days should be discarded."II. Facility policy and proceduresThe Medication Storage policy and procedure, undated, received from the nursing home administrator (NHA) on 11/15/23 at 12:59 p.m. read in pertinent part "Medications will be stored in a secure manner that will provide a safe environment for residents. No discontinued, outdated, or deteriorated drugs or biologics may be retained for use."III. ObservationsOn 11/14/23 at 2:32 p.m. The second floor medication room was reviewed with certified nurse aide with medication authority (CNA/MA) #1. One multidose vial of Aplisol Tuberculin p.. Based on record review and interviews, the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that were significant to the resident for two (#12 and #6) of two residents reviewed out of 29 sample residents. Specifically, the facility failed to assess, document and care plan Resident #12 and Resident #6' s relationship preferences.Findings include: I. Resident #6 A. Resident statusResident #6, age 84, was admitted on 10/9/23. According to the November 2023 computerized physician orders (CPO) the diagnoses included Parkinson' s disease (deterioration of the nervous system), vascular dementia with mood disturbance, depression and insomnia (difficulty sleeping). The 10/15/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) with a score of 11 out of 15. She was dependent for self care, indoor mobility and functional cognition. She required substantial/maximal assistance for eating. She was depe..