Graceland Rehabilitation and Nursing Care Center

In the surveyor’s words

From the most serious findings on record at Graceland Rehabilitation and Nursing Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF725May 1, 2024

  Based on policy review, daily staffing records, medical record review, observation, and interview, the facility failed to ensure a sufficient number of licensed staff was available to provide care and services to all residents based on physician orders when there was no nurse to provide readmission assessments and services for 1 of 3 sampled residents (Resident #1) readmitted to the Crown Ventilation Unit on 4/4/2024 and failed to administer significant and other medications for 20 of 21 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, and #24 ) sampled residents reviewed on the Crown Unit. […]

• Immediate jeopardy, patternF760May 1, 2024

  Based on policy review, medical record review, and interview, the facility failed to ensure residents were free from significant medication errors for 25 of 26 sample residents (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, #24, #35, #36, #38, #40, and #41) reviewed for medication administration. The facility's failure resulted in Immediate Jeopardy (IJ) when the residents' medications were not administered as prescribed for December 2023, January 2024, February 2024, March 2024, and April 2024, and had the likelihood to cause serious adverse outcomes. […]

• Immediate jeopardy, patternF835May 1, 2024

  Based on job description review, record review, medical record review, and interview, the facility Administration failed to administer the facility in a manner that provided oversight of the care being provided to residents, and ensure staff were sufficient in numbers and competent in their duties to provide care and services per physician orders and to meet the individualized needs of all residents. The facility Administration failed to have a system in place to ensure sufficient licensed nursing staff were available and with the knowledge and skills necessary to ensure residents were free from significant medication errors when medications were not administered as ordered by the physician for 25 of 26 sample residents (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15,… […]

• Immediate jeopardy, patternF867May 1, 2024

  Based on job description review, facility document review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI /QA) committee failed to ensure a QAPI program that identified, implemented actions, and monitored serious issues affecting facility staffing, quality of care, prescribed care and services, and residents' rights for 20 of 21 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23 and #24 ) sampled residents reviewed for prescribed medications, treatments, care and services during [DATE], February 2024, [DATE] and [DATE]. […]

• Immediate jeopardy, patternF880May 1, 2024

  Based on policy review, user instruction manual review, job description review, medical record review, observation, and interview, the facility failed to ensure staff practices to prevent the potential spread of infection were maintained when multi-use blood glucometers were not cleaned and disinfected after/between resident testing to prevent cross-contamination of bloodborne pathogens for 5 of 9 sampled residents (Resident #9, #10, #11, #12, and #13) reviewed for blood glucose monitoring, when 1 of 3 nurses (Licensed Practical Nurse (LPN) A) failed to use appropriate Personal Protective Equipment (PPE) when providing care to Residents #9, #10, #11, #12, #17, and #18, and when staff failed to ensure reusable equipment was cleaned and disinfected when 2 of 2 staff members (Certified… […]