Grand River Health Care Center

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.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Resident Rights Deficiencies

Give residents a notice of rights, rules, services and charges.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Nutrition and Dietary Deficiencies

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

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

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.

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.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a).The initial comments (ID Prefix Tag # K 000) are informational only and a representation of the facility' s general characteristics. The facility is a Type II (222) two story building, and licensed for eighty-seven (87) residents. Census on day of survey was 47. The facility was built/occupied in 2021 and the existing building (used the same address) was completely removed. The facility is equipped with a full National Fire Protection Association (NFPA) 13 automatic fire suppression system. This survey, conducted March 1, 2024, included an inspection for compliance with the fire safety requirements of Chapter 18 of NFPA-101, Life Safety Code, (2012 edition), published by the National Fire Protection Association.The survey concluded with a discussion of the deficiencies with the Director of Facilities (teleconference) and the Maintenance Director. Through observation during documentation review, it was determined that the facility failed to meet the health care facilities code requirements in accordance with NFPA 99 and NFPA 110. This was evidenced by: 1) No documentation of annual fuel quality testNFPA 110. NFPA 110, Section 8.3.8 a fuel quality test shall be performed at least annually using approved ASTM standards.These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within all of the smoke compartments. Deficient items were discussed with the Facilities Manager during the survey and again with the Facilities Manager and the Facility Administrator (via telephone) during the exit conference.

A recertification survey was conducted from 2/5/24 and 2/8/24. Six deficiencies were cited. An Emergency Preparedness survey was conducted from 2/5/24 to 2/8/24. No deficiencies were cited. Based on observation, record review and interviews, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for one (#27) of four residents reviewed for accident hazards out of 30 sample residents.Specifically, the facility failed to ensure timely, effective and properly communicated interventions were i.. Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner for two out of four kitchens. Specifically, the facility failed to ensure: -Staff used adequate hand hygiene while serving meals and touched ready-to-eat food appropriately; and,-Residents were offered and enc.. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one out of three units at the facility.Specifically, the facility failed to ensure housekeeping staff:-Follo.. Based on observations and interviews, the facility failed to provide services in accordance with currently accepted professional principles.Specifically, the facility failed to follow accepted standards of practice for medication administration by setting up medications prior to the resident being ready for administration. Findings include:I. Prof.. Based on observations, interviews and record review, the facility failed to address and/or act promptly upon the grievances and recommendations during resident council on issues of resident care and life in the facility that were important to the residents.Specifically, the facility failed to:-Ensure effective interventions were implemented and s.. Based on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater.Specifically, the facility medication administration observation error rate was 7.32% or three errors out of 41 opportunities.Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G.. Based on record review and interviews the facility failed to coordinate assessments with the preadmission screening and resident review (PASRR) program for one (#9) of three residents reviewed for PASRR out of 30 sample residents.Specifically, the facility failed to:-Submit a PASRR level I after Resident #9 had multiple changes in her mo.. Based on record review and interviews, the facility failed to ensure a resident who upon admission displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct an assessed problem and/or to attain the highest practicable mental and psychosocial well-being for one (.. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.