Heritage Hall Grundy

In the surveyor’s words

From the most serious findings on record at Heritage Hall Grundy, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF921Feb 28, 2023

  Based on observation, staff interview, resident review, and family interview, the facility staff failed to maintain a clean and homelike environment on 2 of 2 wings. The findings included: 02/26/23 during initial tour of the facility the surveyors identified a pervasive smell of urine throughout the facility. 02/26/23 at approximately 2:50 p.m., during an interview with a family member of a resident of the facility the family member stated the facility always had an odor. 02/27/23 08:45 a.m., Licensed Practical Nurse (LPN) #1 stated the facility had an odor at times. The surveyor again identified a strong odor on the C hall of the building. […]

• No harm, potential for more than minimal, patternF756Mar 18, 2021

  Based on staff interview and clinical record review, facility staff failed to ensure that Drug Regimen Review reports were addressed by the physician and that documentation concerning the reviews was placed in the clinical record while reviewing the sample of 24 records. The findings included: During clinical record reviews on 3/17/2021, surveyors were unable to find documentation of drug regimen reviews (DRR) in the clinical records. A surveyor interviewed the director of nursing (DON) on 3/17/2021. The DON reported being unaware that the pharmacy review reports were supposed to be reviewed, reported to the physician, and placed in the clinical records. From November 2020 through March 17 2021, staff did not review pharmacy recommendations or place reviews on the resident records. […]

• No harm, potential for more than minimal, isolatedF695Feb 28, 2023

  Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to follow physicians orders regarding oxygen therapy for 1 of 24 residents, Resident #34. The findings included: Resident #34's clinical record included a physician order for oxygen at 3 liters per minute. The surveyor observed the oxygen to be set at 6 liters per minute. Resident #34's diagnoses included, but were not limited to, obstructive sleep apnea, chronic obstructive pulmonary disease, and anxiety disorder. Section C (cognitive patterns) of Resident #34's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/09/22 included a brief interview for mental status (BIMS) score of 9 out of a possible 15 points. […]

• No harm, potential for more than minimal, isolatedF842Feb 28, 2023

  Based on staff interview and clinical record review, the facility staff failed to maintain complete and accurate clinical records for 2 of 24 residents, Residents #34 and #118. The findings included: 1. For Resident #34, the facility staff documented they had administered Resident #34's medications. When in fact Resident #34 was in the hospital and not at the facility. Resident #34's diagnoses included, but were not limited to, obstructive sleep apnea, chronic obstructive pulmonary disease, and anxiety disorder. Section C (cognitive patterns) of Resident #34's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/09/22 included a brief interview for mental status (BIMS) summary score of 9 out of a possible 15 points. […]

• No harm, potential for more than minimal, isolatedF607Mar 18, 2021

  Based on staff interview, facility document review and employee record review the facility staff failed to implement facility policy for the screening of new employees for 3 of 25 new employees, #14, #15, and #21. The findings included: For new employee #14 and #21 the facility staff failed to obtain reference checks and for new employee #15 the facility staff failed to obtain criminal background checks per the facility abuse policy. The surveyor reviewed 25 records for new hire employees on 03/17/21. The surveyor could not locate references for new employee #14, a CNA (certified nursing aide) with a hire date of 11/16/2020, and new employee #21, a CNA with a hire date of 01/15/21. […]