A Grace Sub Acute & Skilled Care

In the surveyor’s words

From the most serious findings on record at A Grace Sub Acute & Skilled Care, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 10, 2022

  Based on observation, interview and record review, the facility failed to ensure treatment was provided after a sacrococcyx (base of the spine and tailbone) wound was identified for one of three residents (Resident 1) when: 1. Failure to assess and document the sacrococcyx wound size and condition accurately. 2. Failure to implement timely treatment as ordered by the wound physician. 3. Failure to notify the physician in accordance with the facility's policy and procedures regarding Resident 1's worsening sacrococcyx wound during weekly assessments of the wound. 4. […]

• No harm, potential for more than minimal, patternF658Oct 18, 2024

  Based on observation, interviews, and record review, the facility failed to ensure professional standards of practice were followed for five out of 22 sampled residents (Residents 25, 35, 75, 93, and 98) when: For Residents 25, 35, 93, and 98, there were incomplete physicians orders, which had the potential for unsafe implementation of the orders and untimely treatment or intervention residents' medical conditions. For Resident 75, the staff took the blood pressure (BP) on the same arm where the resident has the AV fistula (arteriovenous fistula, connection that's made between an artery and a vein for dialysis access), did not monitor her intake and output (the measurement of the fluids that enter the body and the fluids that leave the body). […]

• No harm, potential for more than minimal, patternF700Oct 18, 2024

  Based on observation, interview, and record review, the facility failed to offer and/or attempt alternatives prior to the use of side rails (or bed rails, adjustable rigid bars attached to the side of a bed [examples include safety rails, grab bars, and assist bars]) for 18 of 22 sampled residents (Residents 66, 38, 75, 77, 13, 4, 9, 5, 73, 57, 29, 54, 98, 6, 99, 28, 82, and 16) and 77 nonsampled residents. This failure had the potential to place the residents at risk of entrapment and serious injury. Findings: 1. During an observation in Resident 66's room on 10/14/24 at 8:41 a.m., Resident 66 was sitting in bed. […]

• No harm, potential for more than minimal, patternF755Oct 18, 2024

  Based on interview and record review, the facility failed to ensure accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) and document medication administration as in accordance with the facility policy and procedures (P&P) for 3 out of 5 residents (Residents 35, 39, and 85). The failure had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally). […]

• No harm, potential for more than minimal, patternF812Oct 18, 2024

  Based on observation, interview, and policy review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. Undated food items, food past their used by date, bananas with black spots, partially soft and ruined tomatoes, dry green onion were found in the refrigerator and on the shelves in the kitchen; 2. A tube of Auto-Chlor test strips (used to test the chemical concentration of cleaning solutions to ensure that sanitizers are used appropriately in dishwashers, sinks, and buckets) was expired; and 3. […]