Inspection Reports for
Granby House

The facility failed to provide residents reasonable access to a phone in a private environment, as the phone was located at the nurses' station with staff nearby, resulting in lack of privacy for residents when using the phone. Interviews and observations confirmed the issue and the facility acknowledged the lack of privacy.

The visit was complaint-related due to a resident elopement incident. The resident was found outside the facility after the front door alarm was unplugged. The resident sustained injuries from a fall. The complaint was substantiated with findings of actual harm.

The facility failed to ensure the resident's environment was free from accident hazards by allowing the front door alarm to be turned off, which led to a resident elopement and fall causing injuries. Additionally, the facility did not conduct a complete investigation or root cause analysis of the incident and lacked a specific policy for door alarms and locking mechanisms.

The complaint investigation substantiated that Resident #1 did not receive levothyroxine medication as ordered from admission until approximately one month later. The investigation also found multiple instances of staff failing to perform hand hygiene and gowning as required for residents with wounds and enhanced barrier precautions.

The facility failed to administer levothyroxine as ordered to Resident #1, resulting in a medication error. Additionally, the facility failed to maintain proper infection control practices, including hand hygiene and use of gowns during care for residents with enhanced barrier precautions, affecting multiple residents. Staff interviews and observations confirmed lapses in compliance with infection control policies.

The facility was found deficient in multiple areas including failure to promote resident self-determination regarding bathing, incomplete abuse prevention checks, delayed PASARR screening, untimely lab draws, inadequate shower provision for dependent residents, lack of communication with dialysis center, nurse aides not completing training timely, failure to provide pureed diet components as per menu, incomplete infection prevention program implementation including enhanced barrier precautions, incomplete tuberculosis screening for staff, unsanitary kitchen and dining area conditions, and ineffective pest control resulting in fly infestations.

The complaint investigation was substantiated by observation, record review, interviews, and video evidence showing a former employee removing a fentanyl patch from Resident #1. The facility notified the physician, hospice agency, police, resident's family, and state agency.

The facility failed to protect residents from misappropriation of property, specifically a fentanyl patch missing from Resident #1. The investigation included interviews, review of surveillance footage, and staff statements, confirming a former employee removed the patch. The facility took corrective actions including notifying authorities, changing access codes, and staff education.

The facility was found deficient in timely treatment of a urinary tract infection for one resident, failure to provide appropriate psychosocial care and care planning for a resident with a history of suicidal ideation and trauma, medication errors related to insulin administration, and inadequate monitoring and maintenance of dishwashing machine sanitizing and temperature levels.

The facility was found deficient in multiple areas including failure to provide required Medicare Part A discharge notices, incomplete discharge summaries, inadequate documentation and provision of activities for a hearing-impaired resident, lack of assessments and consents for bed rail use, failure to meet behavioral health needs of a resident with depression and hearing loss, and food safety violations including uncovered food, failure to wear beard restraints, and improper temperature monitoring of refrigeration and freezer units.