Grand Trace Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Grand Trace Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF656Mar 27, 2025

  Based on observation, interviews, record reviews, and policy review, the facility failed to develop and implement comprehensive, resident-centered care plan interventions for one (1) of (20) residents reviewed for care plans, Resident #33. Findings included: A review of the facility policy Plans of Care, dated 09/25/17, revealed: Policy . Procedure: Develop and implement an individualized Person-Centered comprehensive plan of care by the interdisciplinary team that includes but is not limited to appropriate staff or professionals in the disciplines as determined by the resident's needs A review of the Care Plan Report, initiated 03/24/25, revealed Focus: The resident has a pressure injury sacrum .Interventions .Cleanse the sacral wound with normal saline or wound cleanser, pat dry, apply… […]

• Actual harm, isolatedF686Mar 27, 2025

  Based on observation, interview, record review, and policy review, the facility failed to follow physician orders and professional standards of practice related to wound care, as evidenced by wounds not being cleansed and dried according to physician orders, pain not being managed during treatment, and all treatment orders not being completed, resulting in inadequate wound care for a resident with multiple pressure ulcers for one (1) of two (2) residents observed for wound care (Resident #33), Findings included: On 03/26/25 at 10:53 AM, an observation of wound care was conducted by Licensed Practical Nurse (LPN) #1 with assistance from Certified Nurse Aides (CNAs). […]

• Actual harm, isolatedF697Mar 27, 2025

  Based on observation, interview, and record review, the facility failed to manage pain for residnets when the facility failed to ensure pain medication was administered prior to wound care for Resident #33, resulting in the resident exhibiting signs of pain during the procedure and failed to ensure ordered pain medication was available for Resident #169, resulting in unaddressed pain and a lack of adequate symptom control for two (2) of 20 sampled residents. Findings included: A review of the facility's policy titled Pain Management Guideline, with a revision date of 02/21/25 revealed, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the residents' goals and preferences . […]

• Actual harm, isolatedF689Sep 7, 2023

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was transported in the facility van in a safe manner. Resident #1's wheelchair tilted causing a fall during transport, resulting in injury for one (1) of five (5) residents reviewed for accidents. Resident #1. Findings include: Review of facility policy and procedure, Driver/Vehicle Safety dated 8/30/17, revealed, Purpose: To provide guidance for safe handling and operating of center owned vehicle while transporting patient/residents. Process: .4. Wheelchairs to be secured 5. Complete Transport Securement checklist each time a resident wheelchair is placed in the vehicle . […]

• No harm, potential for more than minimal, widespreadF727Mar 27, 2025

  Based on interviews and record review, the facility failed to ensure the presence of a Registered Nurse (RN) for at least eight (8) hours a day, seven (7) days a week as required, for eight (8) of (19) days reviewed. Findings included: On 03/27/25 at 11:50 AM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that she had been told by the facility's Nurse Consultant that the Director of Nursing (DON) could be counted as the RN and that she, as the LPN, could also be included on the staffing grid. She stated that at a previous facility, she was not allowed to count the DON or herself on the staffing report unless they completed direct care hours. […]