Gracemore Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Gracemore Nursing and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF550Mar 9, 2025

  Based on observations, staff interviews, and record review, the facility failed to ensure urinary catheter drainage bags were covered to protect the dignity of three of four residents (R) (R1, R6, and R23) with catheters. Findings include: 1. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R1 revealed in section C (Cognitive Patterns)- a Basic Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment, G (Functional Status)-substantial assistance and dependent for most tasks, H (Bowel and Bladder)-always incontinent of bladder and bowels, I (Active Diagnosis)-(including but not limited to), malignant neoplasm of colon, unspecified and pressure ulcer of left buttock, stage 4, and chronic kidney disease stage 3 unspecified. […]

• No harm, potential for more than minimal, isolatedF609Mar 9, 2025

  Based on staff interviews, record review, and review of the facility policy titled, Abuse, Prohibition Policy, and Procedures, the facility failed to report to the State Survey Agency (SSA) within the required two-hour time frame an allegation of staff to resident abuse for one of 21 sampled residents (R) (R24) reviewed for abuse. Findings include: Review of the facility policy titled Abuse, Prohibition Policy and Procedures dated January 2017 stated under Policy Statement: It is the intent of this facility to actively preserve each resident 's right to be free from mistreatment, neglect, abuse or misappropriation of resident property. We believe that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. […]

• No harm, potential for more than minimal, isolatedF623Mar 9, 2025

  Based on staff interviews, record review, and review of the facility policy titled, Notice of transfer/Discharge, the facility failed to ensure transfer discharge notifications were administered to two of three residents (R) (R4 and R20). Specifically, the facility failed to ensure that R4 and R20 received written transfer documentation that included the bed hold policy and information pertaining to the reason for the transfer from the facility. Findings include: Review of the facility policy titled, Notice of transfer/Discharge, dated March 2017 revealed under Immediate Transfer/Discharge number 1. Notice of transfer and discharge will be made as as practicable when: a. The health of the resident or other residents is threatened; c. […]

• No harm, potential for more than minimal, isolatedF625Mar 9, 2025

  Based on staff interviews, record review, and review of the facility policy titled, Notice of transfer/Discharge, the facility failed to ensure transfer discharge notifications were administered to two of three residents (R) (R4 and R20). Specifically, the facility failed to ensure that R4 and R20 received written transfer documentation that included the bed hold policy and information pertaining to the cost of reserving the bed while out of the facility. Review of the facility policy titled, Notice of transfer/Discharge, dated March 2017 revealed under Immediate Transfer/Discharge number 1. Notice of transfer and discharge will be made as as practicable when: a. The health of the resident or other residents is threatened; 2. The notice will include the following: a. […]

• No harm, potential for more than minimal, isolatedF656Mar 9, 2025

  Based on observation, staff interviews, record review, and review of the facility policy titled, Care Plans-Comprehensive, the facility failed to develop a care plan for two of 21 sampled residents (R) (R28 and R25). The deficient practice had the potential to affect the delivery of the proper care and services provided for R28 and R25. Findings include: Review of facility policy titled Care Plans-Comprehensive revised 4/18/2017 revealed under Interpretation and Implementation 1. Our facility's care planning/interdisciplinary team in coordination with the resident, his/her family or representative develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. […]