Gridley Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF600Jun 6, 2023

  Based on observation, interview, and record review the facility failed to protect one of two sampled residents (Resident 1) from abuse when Certified Nurse's Assistant (CNA) 1 roughly threw Resident 1 into bed, put a pillow on her face, and hit her on her head. This incident was heard by Resident 2. This resulted in Resident 1 to have an injury to the head with bruising and pain; and Resident 1 and Resident 2 to experience emotional distress. Findings: Review of a policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 4/4/21, indicated that the facility would protect residents from being abused by facility staff, ensure adequate oversight, and implement policies and procedures that would identify and prevent abuse. […]

• No harm, potential for more than minimal, widespreadF812Jun 22, 2023

  Based on observation, interview, and record review the facility failed to maintain proper sanitation in the cold food storage. This failure had the potential for contamination of food products which could result in food-borne illness to residents. Findings: A review was made of a facility policy titled Environment, revised 9/2017, which indicated that the facility will ensure that the kitchen is maintained in a clean and sanitary manner, and will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. During a concurrent observation and interview with the Dietary Manager 2 (DM 2) on 6/21/23 at 11:35 am, potentially contaminating material was noted on shelves and floor of the walk-in refrigerator. […]

• No harm, potential for more than minimal, widespreadF865Feb 17, 2022

  Based on interview and record review, the facility failed to ensure care and services met accepted standards of quality when the Quality Assurance and Performance Improvement (QAPI) did not identify and correct quality deficiencies when: 1. Dietary services did not have oversight and qualified dietary staff . Refer to F 801 and F 812. 2. Facility resident council complaints were not addressed. 3. Pharmacy services related to administration, labeling, and storage did not meet standards 4. Fall and Pyschotropic (medication that alter mood/behavior) committees did not identify resident risk factors for falls and unecessary medications. […]

• No harm, potential for more than minimal, widespreadF867Feb 17, 2022

  Based on interview and record review, the facility's Quality Assessment and Assurance (QA) committee failed to develop and implement plans of action to correct identified facility issues related to: 1. Fall and [CONDITION(S)] (medication that alter mood/behavior) committees did not identify resident risk factors for falls and unnecessary medications. 2. Pharmacy services related to administration, labeling, and storage did not meet standards. 3. Dietary services did not have oversight and qualified dietary staff . Refer to F 801 and F 812. 4. […]

• No harm, potential for more than minimal, widespreadF868Feb 17, 2022

  Based on interview and record review, the facility's Quality Assessment and Assurance Program Improvemnt (QAPI) committee failed to ensure the Medical Director (MD) or a representative was present at each quarterly meeting. This failure had the potential for resident quality of life and care issues not to be resolved. Findings: Review of QAPI Sign-in Sheet dated 9/10/21, 11/21/21, and 12/15/21, indicated that both the Medical Director (MD) and Pharmacist (Pharm) 1 did not attend or participate in the QAPI meetings. In a concurrent interview and record review on 2/17/22 at 11:05 AM, Administrator (Admin) confirmed the MD and Pharm 1 did not attend the last quarter of 2021 QAPI meetings. Admin stated the previous administration did not have evidence of QAPI meeting notes or documentation.