Graduate Post Acute

In the surveyor’s words

From the most serious findings on record at Graduate Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 25, 2025

  Based on review of facility policies and documentation, clinical record review and interviews with staff, it was determined the facility failed to provide adequate supervision to one of ten residents reviewed (Resident R1), who did not have a leave of absence (LOA) order. This failure resulted in Resident R1 exiting the third floor via elevator and walking out the front entrance of the facility. Resident R1 was located two hours after the resident exited the facility approximately 1.2 miles away from the facility in a busy [NAME] area. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy past non-compliance. […]

• Immediate jeopardy, isolatedF689Jan 31, 2025

  Based on review of facility policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide adequate supervision to one of one resident reviewed (Resident R1) who was at risk for elopement. This failure resulted in Resident R1 exiting the third floor via elevator and walking out the front entrance doors. Resident R1 was unable to be located for over 24 hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1) Findings include: Review of facility policy, Wander Management and Elopement Prevention dated March 2022, revealed that the facility will maintain the safety of residents who wander and/or at risk for elopement. […]

• Actual harm, isolatedF692Sep 8, 2022

  Based on review of clinical records, facility policies and procedures, and interviews with residents and staff, it was determined that the facility failed to monitor a resident's weight and nutritional status resulting in harm to Resident R5 who sustained an unplanned 21.8 pounds weight loss (23.7 %) in 2 months, for one of seven residents reviewed. (Resident R5) Findings include: Review of facility policy, Weight Measurement dated March 2018, revealed that after weight is obtained it is to be compared to the previous weight. If there is a discrepancy, review with the nurse and weigh the patient again. Discrepancies are considered to be 5 lbs. (pounds) if patient is over 100 lbs., 2.5 lbs. if patient is 99 lbs. or under. […]

• No harm, potential for more than minimal, widespreadF801Nov 22, 2024

  Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services, as required (Employee E8) Findings include: Observation tour on November 19, 2024 at 10:00 a.m. with Employee E8, Food Service Director (FSD) stated that his responsibilities included the oversight of ordering, receiving, storing and preparation and service of food and that he had been working at the facility for one and one half years. Interview on November 19, 2024 at 1:00 p.m. […]

• No harm, potential for more than minimal, widespreadF880Feb 28, 2024

  Based on observations, interview with staff and review of facility provided documentation, it was determined that the facility did not provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections related to hand hygiene and maintaining an effective prevention program related to infection surveillance. (Unit 3, 3rd floor). The facility failed to conduct an infection control surveillance for identifying, tracking and monitoring and or reporting infections, communicable diseases and outbreak among residents. Findings include: During medication administration observation on February 26, 2024 at 9:30 a.m. […]