Deficiencies (last 7 years)
Deficiencies (over 7 years)
12.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
129% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
87% occupied
Based on a April 2025 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 2
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to evaluate compliance with residents' rights regarding reasonable access to private telephone use in the facility.
Findings
The facility failed to provide all residents reasonable access to a phone in a private environment, as the phone was located at the nurses' station without privacy for residents. Interviews and observations confirmed the lack of privacy and staff acknowledged the issue.
Deficiencies (2)
F576 Right to Forms of Communication with Privacy: The facility failed to provide all residents reasonable access to a phone in a private environment, as the phone was located at the nurses' station providing a lack of privacy for two residents.
A8034 Telephone-Private Calls: Telephones appropriate to residents' needs shall be accessible at all times and enable private calls. This regulation was not met as evidenced by the F576 deficiency.
Report Facts
Facility census: 52
Inspection Report
Census: 52
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with residents' rights to reasonable access and privacy in their use of communication methods, specifically regarding the use of a phone located at the nurses' station.
Findings
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.
Deficiencies (1)
Failure to provide residents reasonable access to and privacy in their use of communication methods, specifically the phone located at the nurses' station.
Report Facts
Facility census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding the phone location and privacy concerns |
| Certified Nurse Aide B | Certified Nurse Aide (CNA) | Interviewed regarding staff presence at nurses' desk and phone use |
| Certified Medication Technician C | Certified Medication Technician (CMT) | Interviewed regarding phone use and staff presence at nurses' desk |
| Administrator | Interviewed regarding privacy concerns and efforts to obtain a phone for residents |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Feb 25, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident exiting the building unsupervised and sustaining injuries from a fall.
Complaint Details
The investigation was triggered by a complaint regarding a resident who exited the building when the front door alarm was turned off, resulting in injuries. The complaint was substantiated by findings of inadequate supervision and failure to maintain safety devices.
Findings
The facility failed to ensure the resident's environment remained free of accident hazards, specifically related to a front door alarm being turned off. The facility also did not conduct a complete investigation into the elopement and fall, nor did it have a policy specific to door alarms and locking mechanisms.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) The facility failed to ensure the resident environment remained free of accident hazards when the front door alarm was turned off, resulting in a resident exiting the building and sustaining injuries from a fall. The facility also lacked a policy specific to door alarms and locking mechanisms.
A4074 19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave Each resident shall receive 24-hour protective oversight and supervision. The facility failed to meet this requirement as evidenced by the incident referenced in F689.
Report Facts
Resident census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Registered Nurse | Documented resident's fall and assisted resident after incident |
| Certified Medication Technician D | Certified Medication Technician | Reported on door alarm monitoring and resident checks |
| Nurse Aide B | Nurse Aide | Assisted in locating resident and providing care after fall |
| Nurse Aide C | Nurse Aide | Assisted in locating resident and providing care after fall |
| Maintenance Director | Maintenance Director | Reported no prior knowledge of door alarm issues |
| Director of Nursing | Director of Nursing | Involved in resident assessment and communication with family |
| Administrator | Administrator | Oversaw investigation and plan of correction |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Date: Feb 25, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a resident exited the building after the front door alarm was turned off, resulting in injuries from a fall.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to ensure the resident's environment remained free of accident hazards when the front door alarm was turned off, resulting in a resident exiting the building and sustaining injuries from a fall.
Failed to document a complete investigation into the elopement and fall including a root cause analysis.
Facility did not provide a policy specific to the door alarms and locking mechanisms.
Report Facts
Residents present during inspection: 54
Incident date: Feb 23, 2025
Incident time: 130
Care plan date: Jul 30, 2024
MDS assessment date: Feb 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Documented resident fall, assisted resident, and provided interview details about the incident |
| NA B | Nurse Aide | Participated in resident search, found resident outside, assisted with care, and provided interview details |
| NA C | Nurse Aide | Participated in resident search and provided interview details |
| CMT D | Certified Medication Technician | Provided interview regarding door alarm monitoring and resident wandering |
| Maintenance Director | Provided interview about door alarm system and maintenance reporting | |
| DON | Director of Nursing | Provided interview about door alarms, resident condition, and incident response |
| Administrator | Provided interview about door alarm system and policies |
Inspection Report
Plan of Correction
Census: 51
Deficiencies: 2
Date: Jan 30, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Granby House, detailing regulatory findings related to professional standards and infection control.
Findings
The facility failed to provide care per professional standards when staff did not administer levothyroxine medication as ordered for one resident. The facility also failed to maintain an effective infection control program, including proper hand hygiene and gowning for residents requiring enhanced barrier precautions.
Deficiencies (2)
F658: The facility failed to provide care per professional standards when staff failed to administer levothyroxine medication as ordered for one resident. Documentation and communication errors contributed to the missed medication.
F880: The facility failed to establish and maintain an effective infection control program when staff failed to practice proper hand hygiene and gowning for residents requiring enhanced barrier precautions. This put residents at risk of infection.
Report Facts
Facility census: 51
Completion date for F658 correction: 2025
Completion date for F880 correction: 2025
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Date: Jan 30, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to administer prescribed medication (levothyroxine) to a resident and failure to maintain an effective infection prevention and control program, including improper hand hygiene and gowning practices.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to administer levothyroxine medication as ordered to Resident #1.
Failure to establish and maintain an effective infection prevention and control program, including failure to practice proper hand hygiene and gowning for residents with enhanced barrier precautions.
Report Facts
Facility census: 51
Residents affected by medication deficiency: 1
Residents affected by infection control deficiency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding medication administration and infection control |
| Certified Medication Technician B | Certified Medication Technician | Interviewed regarding medication administration |
| Licensed Practical Nurse C | Night Nurse | Interviewed regarding medication administration and infection control |
| Associate Director of Nurse | Associate Director of Nursing (ADON) | Interviewed regarding admission medication process and infection control |
| Administrator | Administrator | Interviewed regarding medication error report and infection control training |
| Certified Nurse Aide D | Certified Nurse Aide | Observed and interviewed regarding infection control practices |
| Certified Nurse Aide E | Certified Nurse Aide | Observed and interviewed regarding infection control practices |
| Certified Nurse Aide F | Certified Nurse Aide | Observed and interviewed regarding infection control practices |
| Certified Nurse Aide G | Certified Nurse Aide | Interviewed regarding infection control practices |
Inspection Report
Life Safety
Census: 46
Capacity: 60
Deficiencies: 16
Date: Jun 27, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations, including emergency lighting, sprinkler system maintenance, fire extinguishers, smoke barriers, fire drills, smoking regulations, electrical systems, and extension cords.
Findings
The facility was found deficient in multiple areas including failure to document required emergency lighting tests, inadequate maintenance of sprinkler systems and fire extinguishers, unsealed penetrations in smoke barriers, incomplete fire drill documentation, improper disposal of smoking materials, and failure to maintain electrical systems and extension cords. These deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (16)
K291 Emergency Lighting: The facility failed to document the required annual 90-minute emergency lighting functional test for 2023 and 2024 and lacked a policy for maintenance and testing of emergency lighting.
K353 Sprinkler System Maintenance: The facility failed to ensure sprinkler heads were free from debris and lacked a policy for sprinkler system maintenance.
K355 Portable Fire Extinguishers: The facility failed to conduct monthly inspections of fire extinguishers as required and lacked a maintenance policy.
K372 Smoke Barrier Construction: The facility failed to maintain smoke resistive properties due to unsealed penetrations in smoke barrier walls and lacked a maintenance policy.
K712 Fire Drills: The facility failed to conduct fire drills at least quarterly on each shift and lacked a policy for fire drills.
K741 Smoking Regulations: The facility failed to ensure proper disposal of smoking materials in designated smoking areas and lacked a smoking policy.
K914 Electrical Systems Maintenance: The facility failed to complete required annual receptacle testing for 2023 and 2024 and lacked a maintenance policy.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility allowed improper use of power taps and extension cords, creating potential fire hazards, and lacked a maintenance policy.
A2016 Fire Extinguisher Monthly Check: The facility failed to maintain documentation and dating of monthly pressure checks on fire extinguishers.
A2034 Sprinkler System Test/Maintain: The facility failed to maintain and test sprinkler systems in accordance with requirements.
A2050 Emergency Lighting: The facility failed to provide emergency lighting of sufficient intensity for safety and lacked documentation of required tests.
A2054 Smoke Section Walls/Doors: The facility failed to maintain required fire-rated smoke barriers and doors.
A2057 Ashtrays Noncombustibles/Safe Disposal: The facility failed to provide safe disposal of smoking materials in designated areas.
A2061 Fire Drill Requirements, Evacuation: The facility failed to conduct the required number of fire drills annually and lacked documentation.
A3030 Electrical Wiring & Equipment Maintained: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70 standards.
A3037 Extension Cords/Duplex Receptacles: The facility failed to ensure extension cords and power taps met safety standards and were properly used.
Report Facts
Facility capacity: 60
Census: 46
Inspection date: Jun 27, 2024
Inspection Report
Routine
Census: 46
Deficiencies: 12
Date: Jun 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, staff training, infection control, facility maintenance, and other operational standards.
Findings
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.
Deficiencies (12)
Failed to promote resident self-determination by not providing routine baths/showers to a resident.
Failed to ensure Nurse Aide Registry checks were completed timely for staff.
Failed to complete required PASARR screening prior to or at admission for a resident.
Failed to obtain ordered blood tests in a timely fashion for a resident.
Failed to provide timely showers and maintain grooming for dependent residents.
Failed to ensure dialysis communication forms were used and follow-up documented.
Failed to ensure nurse aides completed state approved training and competency evaluation timely.
Failed to provide cornbread or comparable substitute for residents on pureed diets as per menu.
Failed to implement enhanced barrier precautions including staff training, PPE use, signage, and gown/glove use for residents with wounds or indwelling devices.
Failed to administer required two-step tuberculosis screening test for six sampled staff members.
Failed to maintain kitchen and dining areas in sanitary and comfortable condition including dirty light fixtures with dead bugs, rusted prep table, dirty ice machine exterior, and dirty stock room floor.
Failed to maintain effective pest control program resulting in multiple flies present in resident rooms and common areas.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Staff affected: 18
Staff affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA KK | Nurse Aide Trainee | Working as nurse aide but delayed clinical training start and unaware of training timeframe |
| NA JJ | Nurse Aide Trainee | Working as nurse aide but delayed clinical training start and unaware of training timeframe |
| NA ZZ | Nurse Aide Trainee | Working as nurse aide but delayed clinical training start and unaware of training timeframe |
| LPN A | Licensed Practical Nurse | Interviewed regarding shower schedule, dialysis communication, and infection control practices |
| CNA F | Certified Nurse Aide | Interviewed regarding shower provision and infection control practices |
| Administrator | Interviewed regarding expectations for showers, infection control, TB screening, pest control, and facility maintenance | |
| Corporate Nurse | Interviewed regarding dialysis communication, infection control, and TB screening | |
| Clinical Instructor | Nurse Aide Program Instructor | Interviewed regarding nurse aide training delays and regulatory requirements |
| Dietary Manager | Interviewed regarding pureed diet provision and kitchen maintenance | |
| Maintenance Director | Interviewed regarding facility maintenance and pest control |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Date: Jun 6, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the misappropriation of a resident's fentanyl patch, a controlled substance, which went missing from the facility.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to protect residents from misappropriation of property, including medications, when a fentanyl patch went missing.
Report Facts
Facility census: 42
Fentanyl patch dosage: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Documented placement of fentanyl patch and witnessed former employee leaving resident's room |
| CNA B | Certified Nurse Aide | Witnessed former employee leaving and assisted in assessing resident |
| Former CNA E | Former Certified Nurse Aide | Identified on camera and by staff as the individual who removed the fentanyl patch |
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 1
Date: Jun 6, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a regulatory inspection of Granby House, addressing a deficiency in protecting residents from misappropriation and exploitation of property.
Findings
The facility failed to protect a resident from misappropriation of a fentanyl patch, which went missing while the resident was in the facility. The Administrator was notified and took corrective actions including staff education, policy review, and replacement of the missing patch at the facility's expense.
Deficiencies (1)
F 602: The resident was not protected from misappropriation of property as a fentanyl patch went missing while the resident was in the facility. The facility census was 42 at the time of the incident.
Report Facts
Facility census: 42
Date of incident: May 26, 2024
Inspection Report
Routine
Census: 51
Deficiencies: 4
Date: Aug 8, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, psychosocial services, and food safety in the nursing home.
Findings
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.
Deficiencies (4)
Failed to ensure timely care and treatment for a resident with a urinary tract infection related to delayed physician notification and antibiotic administration.
Failed to provide appropriate psychosocial care, care planning, and staff awareness for a resident with a history of suicide attempts, suicidal ideation, and personal trauma.
Failed to ensure medication error rate below 5% when insulin pens were not primed prior to administration for two residents.
Failed to monitor and maintain proper sanitizing levels and water temperatures in the dish washing machine, and failed to ensure staff followed acceptable practices to ensure dishware was sufficiently clean and sanitized.
Report Facts
Facility census: 51
Medication error rate: 7.41
Dish washing machine temperature: 110
Dish washing machine sanitizer level: 50
Dish washing machine sanitizer level: 200
Water heater temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | LPN | Administered insulin without priming insulin pens; described insulin administration procedure |
| Registered Nurse A | RN | Documented urine culture order and specimen collection; described communication delays with physician; primed insulin pens prior to administration |
| Director of Nursing | DON | Provided policy and procedural expectations for urine specimen handling, insulin administration, and dishwashing machine monitoring |
| Certified Nurse Assistant F | CNA | Described lack of awareness of resident's suicidal history and need for communication |
| Certified Medication Technician E | CMT | Described lack of awareness of resident's suicidal history and need for communication |
| Social Service Designee | SSD | Completed resident psychosocial assessments; documented trauma history; described communication gaps with nursing staff |
| Dietary Manager | Dietary Manager | Described dishwashing machine monitoring practices and sanitizer testing |
| Dietary Aide D | Dietary Aide | Described dishwashing machine temperature and sanitizer level monitoring |
| Maintenance Director | Maintenance Director | Described water temperature monitoring practices for kitchen and resident areas |
| Administrator | Administrator | Described oversight responsibilities and lack of awareness of dishwashing machine issues |
Inspection Report
Plan of Correction
Census: 51
Deficiencies: 5
Date: Aug 8, 2022
Visit Reason
The document is a plan of correction submitted by Granby House following a survey conducted on 08/08/2022. It addresses deficiencies cited during the inspection related to quality of care, treatment of mental/psychosocial concerns, medication error rates, and food safety.
Findings
The facility failed to ensure timely care for a resident with a Foley catheter and urinary tract infection, failed to provide appropriate psychosocial care for a resident with a psychiatric history, had a medication error rate above five percent affecting two residents, and failed to monitor sanitizing levels and water temperatures in the dishwashing process.
Deficiencies (5)
F684 Quality of care: The facility failed to ensure one resident with a Foley catheter received timely care and services for a urinary tract infection.
F742 Treatment/Services Mental/Psychosocial Concerns: The facility failed to provide appropriate psychosocial care and services, failed to care plan related to psychosocial needs, and failed to ensure staff awareness of psychiatric history for one resident.
F759 Free of Medication Error Rates 5 Percent or More: The facility failed to ensure a medication error rate below five percent when staff made two errors out of 27 opportunities, resulting in an error rate of 7.41 percent affecting two residents.
F760 Residents are Free of Significant Medication Errors: The facility failed to ensure all residents were free of significant medication errors when staff failed to prime an insulin pen prior to administration for two residents.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to monitor and adjust sanitizing levels and water temperatures in the dishwashing machine and failed to ensure staff followed acceptable practices to ensure dishware was sufficiently clean and sanitized.
Report Facts
Facility census: 51
Medication error rate: 7.41
Medication errors: 2
Medication opportunities: 27
Inspection Report
Life Safety
Census: 51
Capacity: 60
Deficiencies: 6
Date: Aug 8, 2022
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations for the facility.
Findings
The facility failed to maintain the integrity of building construction, ensure proper fire alarm system testing and maintenance, maintain sprinkler system functionality and testing, conduct required fire drills, and maintain electrical equipment safely. Multiple unsealed penetrations, obstructed sprinkler heads, and improper storage of oxygen cylinders were noted.
Deficiencies (6)
K161 Building Construction Type and Height: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations between the attic and areas below, risking smoke passage affecting residents and staff.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to document semiannual fire alarm system inspections for 2021 and 2022, risking delayed notification in a fire emergency.
K353 Sprinkler System - Maintenance and Testing: The facility failed to ensure sprinkler heads were free from debris and did not complete timely five-year internal sprinkler pipe inspections, risking sprinkler system malfunction.
K712 Fire Drills: The facility failed to conduct and document fire drills quarterly on each shift as required, risking staff unpreparedness in a fire emergency.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility allowed improper use of power taps and extension cords, risking fire or electrical injury.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to ensure proper storage and separation of oxygen cylinders and combustibles, risking fire hazards.
Report Facts
Facility capacity: 60
Resident census: 51
Fire drills documented: 0
Years since last sprinkler pipe inspection: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding sprinkler system maintenance, fire alarm testing, fire drills, and electrical equipment safety | |
| Administrator | Interviewed regarding facility compliance with fire safety requirements and monitoring responsibilities | |
| Maintenance Supervisor | Responsible for completing repairs and monitoring compliance as per plan of correction |
Inspection Report
Plan of Correction
Census: 46
Deficiencies: 4
Date: Jan 12, 2022
Visit Reason
The document is a Plan of Correction submitted by Granby House following a survey conducted on 01/12/2022. It addresses deficiencies related to treatment and services to prevent and heal pressure ulcers and notice and conveyance of personal funds.
Findings
The facility failed to consistently assess and document complete and thorough weekly skin assessments, and failed to assess, monitor, and document consistently with professional standards to promote healing and prevent infection for two residents with pressure ulcers. The facility also failed to provide a final accounting of resident personal funds within 30 days of discharge for one resident.
Deficiencies (4)
F686 Treatment/Services to Prevent/Heal Pressure Ulcer CFR(s): 483.25(b)(1)(i)(ii) The facility failed to consistently assess and document complete and thorough weekly skin assessments, and failed to assess, monitor and document consistently with professional standards to promote healing and prevent infection for two residents with pressure ulcers.
A4075 Nursing Care per Resident Condition Each resident shall receive personal attention and nursing care in accordance with his/her condition and consistent with current acceptable nursing practice. This regulation is not met as evidenced by Class II. Please refer to F686.
F569 Notice and Conveyance of Personal Funds CFR(s): 483.10(f)(10)(iv)(v) The facility failed to provide a final accounting of resident personal funds and refund the balance of those funds within 30 days of discharge for one resident.
A9010 Discharge Requirement Within 5 Days Within five calendar days of the discharge of a resident, the resident, his/her designee, guardian and conservator shall be given an up-to-date accounting of the resident's personal funds and the balance of the funds and all personal possessions shall be returned to the resident. This requirement is not met as evidenced by Class II. Please refer to F569.
Report Facts
Facility census: 46
Deficiencies cited: 4
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 4
Date: Nov 4, 2021
Visit Reason
The inspection was conducted in response to complaints regarding misappropriation of resident property and abuse/neglect allegations involving staff members.
Complaint Details
Complaint investigations involved allegations of misappropriation of resident property by Nurse Aide NA-A and physical abuse by Nurse Aide NA-D. The allegations were substantiated with evidence including interviews, bank statements, police reports, and staff statements. The facility failed to timely report and investigate the abuse allegations as required.
Findings
The facility failed to protect residents from misappropriation of property by a staff member who used a resident's bank debit card without permission, causing fraudulent charges. The facility also failed to ensure the nurse aide registry was checked for staff with federal indicators and failed to timely report and investigate allegations of resident abuse by staff.
Deficiencies (4)
F602 Free from Misappropriation/Exploitation: The facility failed to protect residents from misappropriation of property when a staff member used a resident's bank debit card without permission, causing fraudulent purchases over $800.00. The facility census was 50.
F607 Develop/Implement Abuse/Neglect Policies: The facility failed to ensure the nurse aide registry was checked for all staff to confirm they did not have a Federal Indicator prohibiting work in a certified facility. The facility census was 50.
F609 Reporting of Alleged Violations: The facility failed to timely report an allegation of staff to resident abuse within the required two-hour timeframe when a staff member allegedly physically abused a resident. The facility census was 50.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to begin an immediate investigation into an allegation of resident abuse when a staff member allegedly physically abused a resident. The facility census was 50.
Report Facts
Facility census: 50
Fraudulent purchases amount: 800
Negative bank balance: 424.84
Fraudulent debit transaction: 804.65
Number of staff with unchecked registry: 2
Timeframe for reporting abuse: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Assistant | Named in misappropriation of resident property finding |
| NA D | Nurse Aide | Named in physical abuse allegation and investigation |
| CNA B | Certified Nurse Aide | Assisted resident in searching for debit card and provided statements |
| LPN E | Licensed Practical Nurse | Reported responsible party for ensuring resident safety and reporting abuse |
| Administrator | Involved in investigation and reporting of abuse and misappropriation | |
| Director of Nursing | DON | Involved in investigation and reporting of abuse allegations |
| Social Service Director | SSD | Provided statements and involved in investigation |
Inspection Report
Plan of Correction
Census: 48
Deficiencies: 2
Date: Sep 21, 2021
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding safe and orderly transfer or discharge of residents, specifically focusing on discharge planning for one resident.
Findings
The facility failed to ensure complete discharge planning for one resident, including confirming arrangements for home health services. Staff did not follow the facility's discharge and transfer policy, resulting in an unsafe and disorderly discharge process.
Deficiencies (2)
F624 Preparation for Safe/Orderly Transfer/Discharge: The facility failed to provide sufficient preparation and orientation to ensure safe and orderly discharge for one resident, including lack of confirmation of home health services.
A8015 19 CSR 30-88.010(15) 30 Day Notice-Transfer/Discharge: The facility did not notify the appropriate parties at least 30 days in advance of transfer or discharge as required by regulation.
Report Facts
Facility census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Massey | Administrator | Signed the inspection report and plan of correction |
| Social Service Director | SSD | Interviewed regarding discharge planning and home health services |
| Licensed Professional Nurse | LPN | Interviewed regarding discharge and home health services setup |
| Director of Nursing | DON | Interviewed regarding discharge process and facility policy |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant CMS and CDC guidelines related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparedness and infection control. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control. No deficiencies were cited during this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 31, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Routine
Census: 44
Deficiencies: 6
Date: Aug 23, 2019
Visit Reason
The inspection was conducted to evaluate compliance with Medicare/Medicaid regulations including resident discharge procedures, behavioral health services, bed rail safety, and food safety practices.
Findings
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.
Deficiencies (6)
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or denial letter at initiation, reduction, or termination of Medicare Part A benefits for two residents.
Failed to complete a comprehensive discharge summary and recapitulation of stay for one resident.
Failed to provide and document activities to meet and support a resident with hearing loss.
Failed to complete documented assessment, quarterly risk/benefit review, and obtain signed consent for use of side rails for five residents.
Failed to ensure one resident with depression and hearing loss received necessary behavioral health services to meet psychosocial well-being.
Failed to protect food from contamination by storing food uncovered, staff failed to wear required beard restraints, and failed to maintain and document proper internal temperatures of refrigeration and freezer units.
Report Facts
Facility census: 44
Residents sampled: 12
Residents affected by discharge notice deficiency: 2
Residents affected by discharge summary deficiency: 1
Residents affected by activity deficiency: 1
Residents affected by bed rail deficiency: 5
Residents affected by behavioral health deficiency: 1
Food temperature readings above recommended: 15
Food temperature readings above recommended: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA A | Dietary Aide | Observed preparing food without beard restraint |
| Dietary Manager | Interviewed regarding food safety and temperature monitoring | |
| Social Services Director | SSD | Interviewed regarding Medicare Part A discharge paperwork |
| Administrator | Interviewed regarding discharge paperwork and food safety | |
| Registered Nurse C | RN | Interviewed regarding resident behavioral health and bed rail use |
| Licensed Practical Nurse E | LPN | Interviewed regarding resident behavioral health and bed rail use |
| Certified Nurse Aide B | CNA | Interviewed regarding resident activities and positioning bars |
| Corporate QA Nurse | Interviewed regarding bed rail assessments and facility policies |
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 6
Date: Aug 23, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with Medicare and Medicaid regulations at Granby House nursing facility.
Findings
The facility was found noncompliant with several regulatory requirements including failure to provide proper Medicaid/Medicare coverage notices, incomplete discharge summaries, inadequate activity programs, improper use and documentation of bed rails, and food safety violations. Multiple deficiencies were cited across nursing care, behavioral health services, and food handling practices.
Deficiencies (6)
F582 Medicaid/Medicare Coverage/ Liability Notice. The facility failed to provide required Medicare Part A notices to residents discharged from Medicare Part A services. The facility census was 44.
F661 Discharge Summary. The facility failed to complete a comprehensive discharge summary and recapitulation of stay for one resident in a sample of 12 residents with a census of 44.
F679 Activities Meet Interest/Needs Each Resident. The facility failed to provide and document activities to meet and support one resident's interests and needs in a sample of 12 residents with a census of 44.
F700 Bedrails. The facility failed to complete documented assessments, obtain consents, and ensure proper use of bed rails for five residents in a sample of 12 with a census of 44.
F740 Behavioral Health Services. The facility failed to provide necessary behavioral health services to attain or maintain the highest practicable mental and psychosocial well-being for one resident in a sample of 12 with a census of 44.
F812 Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to protect food from contamination and maintain proper food storage and handling practices, including failure to wear hair restraints and maintain proper refrigerator temperatures.
Report Facts
Facility census: 44
Sample size: 12
Number of residents with bed rail issues: 5
Inspection Report
Life Safety
Census: 44
Capacity: 60
Deficiencies: 2
Date: Aug 23, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to maintain the integrity of the building construction by not maintaining the one-hour fire rating of the ceilings due to unsealed penetrations between the attic and shared space above a suspended ceiling. This deficiency had the potential to affect all residents, staff, and visitors.
Deficiencies (2)
K161: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations between the attic and shared space above a suspended ceiling. This condition allowed smoke to pass between the attic and resident-use areas.
A3001: The building was not substantially constructed and maintained in good repair as required by 19 CSR 30-85.032(2).
Report Facts
Facility capacity: 60
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shala Teagins | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 3
Date: Jul 26, 2018
Visit Reason
Annual survey conducted to assess compliance with federal regulations regarding quality of care and psychotropic drug use at Granby House nursing facility.
Findings
The facility failed to provide proper care for a resident with a PICC line, including failure to obtain physician orders and properly document care. The facility also failed to ensure a medication regimen free from unnecessary psychotropic drugs for another resident, with inadequate documentation and monitoring of behavioral symptoms.
Deficiencies (3)
F684 Quality of care: Facility staff failed to obtain physician orders and provide proper care for a resident with a PICC line, resulting in inadequate flushing and dressing changes. Documentation and communication regarding PICC line care were insufficient.
F758 Psychotropic Drugs: Facility failed to ensure residents not using psychotropic drugs were not given them unnecessarily and failed to document indications, target behaviors, and non-pharmacological interventions for one resident. Monitoring and review of psychotropic medication use were inadequate.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by deficiencies F684 and F758.
Report Facts
Facility census: 48
Sample size: 15
Inspection Report
Annual Inspection
Census: 48
Capacity: 60
Deficiencies: 4
Date: Jul 26, 2018
Visit Reason
Annual recertification survey to assess compliance with Life Safety Code and other regulatory requirements.
Findings
The facility failed to conduct a semi-annual fire alarm inspection, maintain the automatic fire sprinkler system properly, conduct required quarterly fire drills, and ensure proper use of power strips in resident rooms. These deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (4)
K345 Fire Alarm System - Testing and Maintenance: The facility failed to conduct a semi-annual fire alarm inspection as required by NFPA 72, 2010 edition.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the automatic fire sprinkler system by allowing sprinkler heads in the attic to remain covered with insulation, potentially delaying activation.
K712 Fire Drills: The facility failed to conduct the required quarterly fire drills at unexpected times on each shift within 20 minutes of each other during the last year.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to ensure proper use of power strips by allowing refrigerators in resident rooms to be plugged into power strips, risking circuit overload.
Report Facts
Facility capacity: 60
Census: 48
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