Grace Heights Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Grace Heights Health & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Sep 11, 2024

  Based on observations and staff interviews, the facility failed to label and date leftover food items stored for use and failed to keep a food storage area clean. These practices occurred in the walk-in refrigerator and had the potential to affect food served to residents. The findings included: An initial tour of the kitchen occurred on 9/8/24 at 9:28 AM. The following concerns were identified: a. Items in the walk-in refrigerator that were opened and labeled, but past the use by date included: - a resealable bag of seven prepared biscuits labeled with a use by date of 9/6/24. - a resealable bag of five hamburger patties with a use by date of 9/5/24. b. […]

• No harm, potential for more than minimal, patternF641May 25, 2022

  Based on record reviews, observations and resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments to reflect the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #55) and urinary continence for 2 of 2 residents reviewed for urinary appliance (Resident #61 and Resident #66). Findings included: 1. Resident #67 was admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #67's annual MDS assessment dated [DATE] revealed resident was not coded as having a dementia diagnosis. Review of Resident #67 revised care plan dated 04/18/22 revealed no care plan specific to dementia. […]

• No harm, potential for more than minimal, patternF656May 25, 2022

  Based on record review, observations and resident and staff interviews, the facility failed to develop a comprehensive person-centered plan of care to address specific needs of the residents in the areas of activities of daily living for 2 of 7 residents reviewed (Resident #57 and Resident #66) and dementia care for 1 of 2 residents reviewed (Resident #67). The findings included: 1. Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #57 was severely impaired for cognitive skills for daily decision making and had fluctuating altered level of consciousness. […]

• No harm, potential for more than minimal, patternF880May 25, 2022

  Based on record reviews, observations and staff interviews, the facility failed to implement their infection control policies and the Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19 when 2 of 2 staff members (Nurse #2) failed to wear an N95 mask prior to entering a room of a COVID-19 positive resident (Resident #252) and (Nurse Aide #1) failed to remove her N95 mask, disinfect her goggles and perform hand hygiene after leaving a room of a COVID-19 positive resident (Resident #251). In addition, 2 of 3 staff members (Nurse #3 and Nurse #1) failed to perform hand hygiene during wound care on 2 of 3 residents (Resident #57 and Resident #61) reviewed. These failures occurred during a COVID-19 pandemic. […]

• No harm, potential for more than minimal, patternF888May 25, 2022

  Based on record review and staff interviews the facility failed to implement an effective process for tracking COVID-19 vaccination status of 5 of 5 facility staff (Nurse Aide (NA) #3, NA #7, NA #8, NA #9, and NA #10) reviewed for COVID-19 Vaccination Status. The facility was currently in outbreak status and failed to have 100% of staff vaccinated. The findings included: The facility's COVID-19 Vaccine policy with no reviewed or revised date, read in part: It is the policy that all persons be offered the COVID-19 vaccine. This includes residents and staff. Staff includes all fulltime, part-time and prn employees, contract staff such as therapy, staffing agency, management company and consultants. […]