Grand River Health Care Center

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews.Specifically, the facility failed to complete a performance review of certified nurse aide (CNA) at least once every 12 months.Findings include:I. Facility Policy and ProcedureThe policy and procedure for annual performance evaluations was requested from the nursing home administrator (NHA) and the director of nursing (DON) on 1/15/26 at 12:37 p.m. On 1/20/26 at 10:46 a.m., the ADON said the facility did not have an applicable policy and procedure for annual performance evaluations As of 1/21/26, no additional policy and procedure documents had been provided by the facility.II. Annual performance reviews for CNA #4, CNA #5, CNA #6, CNA #7 and CNA #8The annual performance reviews for CNA #4, CNA #5, CNA #6, CNA #7 and CNA #8 wererequested from the NHA on 1/13/26 at 6:09 p.m. -However, the facility was unable to provide documentation of annual performance reviews for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide ongoing communication to residents about their rights; and failed to inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility for one (#50) of three residents reviewed out of 28 sample residents.Specifically, the facility failed to provide Resident #50 with a written copy of the facility's room change/move policy and procedure upon the resident's request.Findings include:I. Facility policy and procedureThe Patient Rights and Responsibilities policy and procedure, reviewed 6/4/25, was provided by the nursing home administrator (NHA) on 1/15/26 at 5:19 p.m. It read in pertinent part, The statement of patient rights shall include, but is not limited to, the patient's right to: Receive information in a manner that he/she understands. Communications with the patient shall be effective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#10) of five residents reviewed for medication errors out of 28 sample residents.Specifically, the facility failed to:-Ensure that Resident #10 received warfarin (an anticoagulant medication), a medication with a narrow therapeutic index (a medication where the difference between an effective dose and a toxic dose is very small); and,-Determine how the significant medication error occurred and provide education to nursing staff in order to prevent future occurrences. Findings include:I. Professional referenceAccording to [NAME], P.A., [NAME], A.G et.al, Fundamentals of Nursing, 10th ed., (2023). Elsevier, St. Louis, Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications:1. The right medication2.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment.Specifically, the facility failed to:-Ensure Resident #3's wound care supplies were not taken into Resident #33's bathroom during Resident #33's wound care dressing change; and,-Ensure registered nurse (RN) #3 followed enhanced barrier precautions (EBP), including wearing a protective gown when providing wound care for Resident #33. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 1/20/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part,Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 encouraged hand hygiene prior to meals. Findings include I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved 12/27/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink. II. Facility policy A. The Food Preparation and Service policy, revised 10/2/23, provided by the dietary manager (DM) on 2/8/24 at 3:00 p.m. read in pertinent: Food service staff, including nursing services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop and revise comprehensive care plans for each resident that included the instructions needed to provide effective and person-centered care for one (#10) of four residents out of 30 sample residents. Specifically, the facility failed to: -Update and personalize care plans for Resident #10 who was at high risk for falls; -Update Resident #10's dementia care plan documenting interventions; -Initiate a care plan for Resident #10's refusals to wear oxygen; -Personalize Resident #10's behavioral care plan with interventions to deter his verbal aggression; and, -Personalize Resident #10's care plan for his refusals of care. Findings include: I. Resident status Resident #10, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician order (CPO) diagnoses included injury of the brachial plexus (nerves in the shoulder), chronic respiratory failure with hypoxia (not enough oxygen in the tissues of the body), heart failure,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 in place to prevent skin injuries and the recurrence of skin injuries to Resident #27. Findings include: I. Facility policy The Assisted lift Program policy, reviewed 1/30/23, was provided by the assistant director of nursing (ADON) on 2/7/24 at 2:39 p.m. The policy read in part: (The facility) wants to ensure that its (residents) are cared for safely, while maintaining a safe work environment for its employees. All patients and residents will be assessed with regard to the need for assistance with transfer activities, mobility or repositioning in accordance with (the facility) procedures and requirements. The patients/residents care plan will be established through the use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 (#50) of four residents reviewed out of 30 sample residents. Specifically, the facility failed to: -Initiated therapy as recommended by preadmission screening and resident review (PASRR) Level II until four weeks later and after Resident #50 was experiencing mental health concerns: -Identify the Resident #50 triggers and past trauma to minimize being retraumatized; and, -Allow Resident #50 to have the bed of her preference due to a past traumatizing experience to minimize her trouble sleeping and night terrors. Findings include: I. Facility policy The Behavioral Health Care process and procedure, undated, provided by the nursing home administrator (NHA) on 2/8/24 at 1:06…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 2/12/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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: -Following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (remote controls, light switches, door handles and drawer pulls); -Performed hand hygiene when appropriate; -Cleaning the toilet bowl appropriately; -Cleaned a resident's room from cleaner areas to dirtier areas to avoid spreading dirt and microorganisms; and, -Adhered to disinfectant cleaning guidelines. Finding include: I Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.