Grand Cove Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Grand Cove Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Nov 8, 2023

  Based on interviews and record reviews, the facility failed to ensure nursing staff effectively notified the physician of a resident's injury for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in an immediate jeopardy for Resident #1 on Friday, 10/13/2023 at 7:30 p.m., when S5LPN noted Resident #1's right arm tucked behind her back. She observed the resident's whimpering and her right arm was swollen and puffy. S5LPN notified S9MD's office via fax at approximately 10:30 p.m. that same evening when the physician's office was closed and would have remained closed and not staffed for the weekend. On Monday, 10/16/2023 at 7:11 a.m. […]

• Immediate jeopardy, isolatedF684Nov 8, 2023

  Based on record reviews and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#1) of 3 (#1, #2 and #3) sampled residents. The facility failed to ensure nursing staff: 1. effectively communicated a change in Resident #1's condition to a physician and 2. intervene by following up with the physician after the identified a change in condition for Resident #1 when she continued to display signs of injury and pain. This deficient practice resulted in an immediate jeopardy for Resident #1 on Friday, 10/13/2023 at 7:30 p.m., when S5LPN noted Resident #1's right arm tucked behind her back. […]

• No harm, potential for more than minimal, patternF656May 10, 2023

  Based on records reviewed and interviews, the facility failed to implement the person centered care plan by not following physician orders for 4 (#1, #15, #46, #57 and #58) residents out of a total of 32 sampled residents as evidenced by failing to: 1. obtain a monthly weights as per facility policy and procedure for Resident #1 and, 2. document dietary intake amount for each meal as ordered for Residents #1, #15, #57 and # 58, and, 3. obtain laboratory testing as ordered for Resident #46 This deficient practice had the potential to affect the 79 residents who resided in the facility. Findings: Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses including: End Stage Renal Disease, Diabetes Mellitus, Dysphagia, Dementia, Malnutrition and Depression. […]

• No harm, potential for more than minimal, patternF656Mar 29, 2022

  Based on observations, interviews and records reviewed, the facility failed to implement the person centered care plan by not following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. perform wound care as ordered for Residents # 62, #73 and # 81 and; 2. apply [MEDICATION(S)] powder as ordered for Resident # 81's rash. This deficient practice had the potential to affect the 97 residents who resided in the facility. Findings: Review of facility's policy and procedure titled Dressing Change Policy and Procedure read in part .1 .administer per MD (medical doctor) orders . Resident # 62 Review of Resident # 62's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of wound care, provided by S6TxNurse, was conducted on 03/29/2022 at 11:08 a.m. […]

• No harm, potential for more than minimal, patternF677Mar 29, 2022

  Based on observations, interviews and record reviews, the facility failed to ensure a resident who is unable to carry out Activities of Daily Living (ADL) received the necessary services to maintain good grooming and personal hygiene for 3(#15, #20 and #72) out of 6 (#15, #20, #72, #73, #85, #144) final sampled residents investigated for ADL care. The facility failed to provide: 1. showers/baths for Residents #20 and #72 and; 2. personal grooming and nail care for Resident #20. This deficient practice had the potential to affect the 97 residents in the facility, according to the Resident Census and Conditions that required assistance with ADL. Total census 97. Findings: Resident #20 Review of policy titled Quality of Care, read in part . Bathing. a. […]