Inspection Reports for
Grand Trace Health Care and Rehabilitation

The complaint alleged that Resident #1 did not receive appropriate assessment, diagnostic tests, or diagnosis while at the facility, leading to inappropriate care. The complainant believed Resident #1 also suffered from frontotemporal dementia, which was not diagnosed during the stay. Interviews with staff confirmed inaccurate documentation of dementia and that care was planned based on impaired cognition.

The facility failed to maintain accurate medical records for Resident #1, specifically regarding the diagnosis of dementia. Documentation inaccurately listed dementia despite the resident being admitted with schizoaffective disorder-bipolar type. Interviews confirmed the inaccurate documentation and that care was provided based on impaired cognition rather than dementia diagnosis.

The complaint investigation was substantiated with findings of minimal harm or potential for actual harm affecting some or few residents, including issues with call light accessibility, cleanliness, personal belongings, personal care, and staffing shortages.

The facility failed to provide an accessible call light for a paralyzed resident, maintain a clean and homelike environment for residents, ensure personal hygiene and grooming assistance, and maintain sufficient nursing and CNA staffing to meet resident needs. Several residents reported missing personal belongings and delays in care due to staffing shortages.

The facility was found deficient in multiple areas including failure to maintain a clean and safe environment, incomplete significant change assessments, inaccurate resident assessments, inadequate PASRR screenings and status change notifications, failure to implement baseline care plans timely, inadequate wound care and pain management, supply shortages affecting resident care, improper respiratory care, and failure to maintain an effective QAPI program.

The visit was complaint-related based on multiple anonymous complaints alleging inadequate staffing, failure to provide care such as bathing and incontinent care, and failure to meet residents' needs. Specific complaints included insufficient CNAs on shifts, residents left soiled, and lack of timely assistance.

The facility was found deficient in multiple areas including failure to accommodate resident needs for bariatric beds, failure to ensure timely mail delivery, failure to provide advanced beneficiary notices, failure to provide written transfer notifications, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans for residents with PTSD, inadequate assistance with activities of daily living, failure to provide trauma-informed care, and insufficient nursing staff leading to unmet resident needs.

The investigation was triggered by a complaint regarding an accident on 8/04/23 where Resident #1's wheelchair tilted during transport causing injury. The complaint was substantiated with findings of actual harm. The Transportation Aide was terminated for unrelated reasons. The resident was treated at the hospital and discharged home as planned.

The facility failed to ensure safe transport of Resident #1 in the van, resulting in the wheelchair tilting and the resident sustaining a laceration to the left ear and a skin tear to the left elbow. The Transportation Aide did not secure the wheelchair properly prior to transport, and required safety checklists were not completed before transport.

The visit was complaint-related due to grievances about food quality (cold and bland food) and failure to provide written transfer/discharge notices to resident representatives. The complaints were substantiated as the facility failed to resolve food grievances timely and failed to notify resident representatives in writing of transfers.

The facility failed to ensure Resident Council grievances about food palatability and temperature were resolved timely, affecting eight residents. Additionally, the facility failed to provide written transfer/discharge notices to resident representatives for two residents. The facility also had inaccurate Minimum Data Set (MDS) assessments for four residents and failed to follow proper wound care and infection control procedures for one resident.