Grand Avenue Rest Home

In the surveyor’s words

From the most serious findings on record at Grand Avenue Rest Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Sep 11, 2025

  Based on observation and interview, the facility failed to ensure soiled linen was covered when transporting it through facility. This had the potential to impact all 19 residents of the facility. Findings include: During observation on 9/8/25 at 11:50 a.m., a staff member was observed walking through first floor living room and dining room with uncovered linen basket that also had no liner or bag. There were 4 residents sitting in the living room and 3 residents sitting in the dining room as he walked past. […]

• No harm, potential for more than minimal, widespreadF921Sep 11, 2025

  Based on observation, interview and record review the facility failed to ensure facility was kept sanitary and maintained in good repair which had the potential to affect all 19 residents, staff, and visitors of the facility.Findings include:Walls:During observation on 9/8/25 at 12:18 p.m., wallboard under the hand railing leading to second floor had several areas of missing wallboard and peeling paint showing underlayment. The dining room had curling vinyl tile on the floor along wall the with the window and old-style radiator. A window air conditioner unit was attached to the upper sash of window that had curled up blue masking tape surrounding it while it was wedged into the window on a board. Air space was observed on the bottom of the unit. […]

• No harm, potential for more than minimal, widespreadF657Jan 21, 2025

  Based on interview and record review, the facility failed to prepare resident care plans with an interdisciplinary team (IDT) to include a nursing aide (NA), the attending physician, or a resident/resident representative. This deficiency had the ability to affect all 19 residents. Findings include: During an interview on 1/21/25 at 9:11 a.m., the director of nursing (DON) stated the IDT consists of an RN, the administrator, herself, the social worker, a member from medical records, the infection preventionist (IP) nurse, the minimum data set (MDS) nurse, and a compliance nurse. […]

• No harm, potential for more than minimal, widespreadF727Jan 21, 2025

  Based on interview and record review the facility failed to ensure their director of nursing (DON) was a registered nurse (RN) when the facility had a licensed practical nurse (LPN) in the DON role since 7/30/24. This deficiency had the ability the affect all 19 residents. Findings include: During an interview on 1/16/25 at 11:39 a.m., the administrator stated the DON is a LPN. The administrator she knew the facility has to hire an RN to be in the DON role. There is not a signed DON job description for the current DON. During an email correspondence on 1/16/25 at 2:21 p.m., the administrator stated the DON has been in her role since 7/30/24. During an interview on 1/21/25 at 9:11 a.m., the DON stated she is a LPN who worked a the facility full time. […]

• No harm, potential for more than minimal, widespreadF727Aug 28, 2024

  Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 18 residents at the facility. Findings include: Review of the facility staff schedules and staffing hours from 1/1/24 to 3/31/24 revealed there was no RN scheduled for 1/14/24, 1/20/24, 1/21/24, 1/27/24, 1/28/24, 2/3/24, 2/4/24, 2/16/24, 2/17/24, 2/18/24, 2/24/24, 3/2/24, 3/3/24, 3/9/24, 3/10/24, 3/16/24, 3/17/24, 3/23/24, 3/30/24, and 3/31/24. During interview on 8/26/24 at 9:17 a.m., the interim director on nursing (DON) confirmed the dates identified that there was no RN coverage. […]