Grant Healthcare and Rehabilitation

Based on observation, interview, and review of the facility's policy, the facility failed to prepare and serve food in a safe manner. Observations on 09/09/2025 during lunch tray line preparation staff failed to utilize proper hand hygiene. The findings include:Review of the facility's policy titled Hand Hygiene dated 06/09/2025, revealed for all staff to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene technique when using soap and water to dry thoroughly with a single-use towel and use clean towel to turn off the faucet. The use of gloves does not replace hand hygiene.Observation during initial tour of kitchen on 09/09/2025 at 11:06 AM revealed hand hyenine signage located above the hand sink near the tray line and proper glove use signage above the hand sink between the production area and the dish room. A review of the signage in the kitchen located above the hand sink in the production area, not dated, revealed it stated all employees must wash their hands before returning to work and explained…

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, interview, record review, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and to implement interventions to protect the residents. The facility failed to follow their policy related to ensuring the ice machines and water fountain were properly cleaned. Additionally, the facility failed to ensure Resident (R) 9's catheter was properly secured, and the catheter bag remained off the floor to help prevent infection. The findings include: Review of the facility policy titled Infection Prevention and Control Program dated 02/02/2025 revealed the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and…

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 interview, record review, and review of the facility's policy, the facility failed to keep residents free from abuse for 1 of 25 sampled residents (Resident (R) 341). On [DATE], R341 was physically restrained by Certified Nursing Assistant (CNA) 6 and Licensed Practical Nurse (LPN) 6 while they were providing care which resulted in bruising of both of the resident's forearms. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation, revised date [DATE], revealed, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. The policy also stated, 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate…

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, interview, review of the website https://www.fda.gov/media/74866/download, review of Medication Refrigerator Temperature Guidelines: What You Should Know, and review of the facility's policies, the facility failed to label and store drugs and biologicals in accordance with currently accepted professional principles for 1 of 2 medication refrigerators observed. A multi-use vial of Tuberculin Purified Protein Derivative (PPD) was found in a plastic bag in the door of the refrigerator and was opened and not dated in the Medication Room on Heritage Hall. The findings include: Review of the facility's policy titled, Medication Storage, revised 08/01/2024, revealed it was the policy of the facility to ensure all medications housed on the premises would be stored in accordance with the manufacturer's recommendations to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Review of the facility's policy titled, Medication Administration, revised 02/20/2024, revealed the nurse must identify the expiration date. Per the…

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, interview, review of the facility's policies, review of the manufacturer's directions for use for the Assure Prism Multi-Blood Glucose Monitoring System, and review of the instructions for Clorox Healthcare Bleach Germicidal Wipes, the facility failed to follow standard infection procedures for cleaning and handling 1 of 8 glucometers. The findings include: Review of the facility's policy titled, Routine Cleaning and Disinfection, dated 01/02/2020, revealed the purpose of the policy was to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Review of the facility's policy titled, Blood Glucose Monitoring, dated 01/02/2020, revealed the purpose of the policy was for the facility to perform blood glucose monitoring to diabetic residents as per physician's orders. The policy outlined the procedure for obtaining a resident's blood glucose level. As part of the procedure for obtaining the blood glucose level, the policy stated…

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, interview, and review of facility Policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observation on 07/30/19 at 11:40 AM, revealed food on the steam table was uncovered from 11:40 AM until 12:07 PM, a total of twenty-seven (27) minutes prior to food being served from tray line. In addition, observation on 07/31/19 at 11:40 AM, revealed food on the steam table was uncovered from 11:40 AM until 12:00 PM, a total of twenty (20) minutes, prior to food being served from tray line. Furthermore, observation of a test tray on 07/31/19 at 1:01 PM, revealed milk and juice temperatures were measured at fifty-two (52) degrees Fahrenheit (F), and tuna fish on the test tray was measured at sixty (60) degrees F, indicating cold foods did not hold temperature. The findings include: Review of the facility Food: Preparation Policy, revised 2017, revealed the Dining Services Directors/Cook(s) will be responsible for food preparation techniques which minimize the amount of…

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 interview, record review, and review of the facility's Policy, it was determined the facility failed to implement written policies related to reporting and investigating allegations of abuse. This affected two (2) of eighteen (18) sampled residents (Residents #81 and #31). There was no documented evidence the facility implemented their written abuse policies related to completing a thorough investigation after staff witnessed a resident-to-resident verbal altercation which lead to Resident #81 grabbing a butter knife and threatening to stab Resident #31 on 04/22/19. In addition, there was no documented evidence the facility implemented their written abuse polices related to reporting the alleged violation to State Agencies. (Refer to F-609 and F-610) The findings include: Review of the facility's Policy titled OPS300 Abuse Prohibition Policies and Procedures, revised 07/01/19, revealed anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop…

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 interview, record review, and review of the facility's Policy, it was determined the facility failed to ensure all alleged violations involving abuse are reported immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse, to the Administrator and to State Agencies for two (2) of eighteen (18) sampled residents (Residents #81 and Resident #31). On 07/30/19 at 12:56 PM, Resident #31 reported during an interview with the State Agency (SA) Representative, Resident #81 pulled a knife on him/her a few months ago. Review of Resident #81 Progress Notes, dated 04/22/19, revealed Resident #81 cussed a resident and subsequently picked up a knife off the table and stated he/she would stab the other resident. Staff interviews verified the allegation; however, there was no documented evidence the facility reported the allegation to the Administrator and to State Agencies. The findings include: Review of the facility's Policy titled OPS300 Abuse…

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 interview, record review, and review of the facility's policy, it was determined the facility failed to have evidence that all alleged violations of abuse are thoroughly investigated. This affected two (2) of eighteen (18) sampled residents (Residents #81 and #31). Staff interviews revealed on 04/22/19, Resident #81 was involved in a resident-to-resident verbal altercation with Resident #31 that escalated resulting in Resident #81 grabbing a butter knife from the table and threatening to stab Resident #31. However, there was no documented evidence of an investigation related to this incident. The findings include: Review of the facility's OPS300 Abuse Prohibition Policies and Procedures, dated 06/01/96 and revised 07/01/19, revealed, Only an investigation can rule out abuse, neglect, or mistreatment. An investigation should be initiated within twenty-four (24) hours of an allegation of an allegation of abuse or neglect which should include clinical examination for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. The…

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 interview, record review, and review of facility Policy, it was determined the facility failed to notify the Resident or the Resident's Representative of the transfer/discharge and the reasons for the transfer in writing, for two (2) of eighteen (18) sampled residents (Resident # 36 and Resident #39). Resident #36 was transferred to an acute care hospital, on 05/28/19 with return anticipated; however, there was no documented evidence Resident #36 or his/her Resident Representative received a written notice of transfer/discharge. Additionally, Resident #39 was transferred to an acute care hospital, on 05/18/19 with return anticipated; however, there was no documented evidence Resident #39 or his/her Resident Representative received a written notice of transfer/discharge. The findings include: Review of the facility Discharge and Transfer Policy, revised 02/01/19, revealed Transfer included movement of a patient to a bed outside of the certified Center. Additionally, the Center must immediately inform the patient/resident representative, when there was a decision to transfer…

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 interview, record review, and review of the facility's Policy, it was determined the facility failed to provide written information to the Resident or the Resident Representative related to the Bed-hold Policy at the time of transfer for one (1) of eighteen (18) sampled residents (Resident #39). The facility obtained a Provider's Order to transfer Resident #39 to an acute care facility for evaluation following a change in condition on 05/18/19; however, there was no documented evidence the facility provided the Resident or the Resident's Representative written information related to the facility's Bed-hold Policy related to this transfer. The findings include: Review of the facility's Policy titled, Bed Hold Notice dated 12/14/18, revealed prior to a resident's transfer out of the center to a hospital or for therapeutic leave, the staff member conducting the transfer out will provide both the resident and resident representative, the Bed Hold Policy Notice and Authorization Form. Additionally, the…

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 interview, record review, and review of facility Policy, it was determined the facility failed to develop and implement the Comprehensive Care Plan (CCP) to address the resident's needs for one (1) of eighteen (18) sampled residents (Residents # 63). Resident #63 sustained a fall on 06/19/19, and the facility implemented a tab alarm to the resident's wheelchair as a fall prevention intervention. However, there was no documented evidence the CCP was developed and implemented with an intervention for ongoing re-assessment of the effectiveness of the tab alarm device with necessary modification as necessary. In addition, Resident #63 sustained a fall on 06/27/19. Per the Investigation, the facility determined the Root Cause Analysis (RCA) of the fall event was excess fluid removed during dialysis. However, there was no documented evidence the CCP was developed and implemented related to the intervention based on the Root Cause Analysis (RCA) to communicate with the dialysis clinic related to fluid volume exchange. The findings include: Review of the facility's Person-Centered…

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 interview, record review, and review of the facility Policies, it was determined the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for one (1) of four (4) sampled residents reviewed for falls out of a total sample of eighteen (18) residents (Resident #63). Resident #63 was assessed by the facility to be a Fall Risk, per the admission Assessment, dated 06/10/19. The facility implemented a tab alarm to the resident's wheelchair as a fall intervention, on 06/19/19 after a fall accident/incident. However, there was no documented evidence in the medical record of an assessment for the tab alarm as a least restrictive device or no documented evidence of the reasons why this device would be appropriate/effective for this resident to prevent further falls prior to implementation of the device on 06/19/19, status post fall. In addition, Resident #63 sustained a fall on 06/27/19 and the Root Cause Analysis was identified as excess fluid removed during dialysis. Per the Falls Investigation dated 06/27/19, the facility…

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.