Essentia Health Grace Home

In the surveyor’s words

From the most serious findings on record at Essentia Health Grace Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF803Sep 23, 2021

  Based on observation, interview, and document review, the facility failed to ensure the correct diet was served to 3 of 3 residents (R1, R2, R3) reviewed for diet. This resulted in an immediate jeopardy for R1, who was served bite sized fruit larger than ½ inch in size per physician orders which caused R1 to choke and had to be walked to the Emergency Department where R1 self-expelled a piece of fruit 2.7 by 2.0 cm in size. Additionally, R2 and R3 were served food against physician orders. The immediate jeopardy began on 9/9/21, when R1 was served bite sized fruit larger than ½ inch in size per physician orders, which resulted in R1 choking. […]

• Actual harm, isolatedF656Feb 27, 2025

  Based on observation, interview and document review, the facility failed to ensure care plan interventions were implemented for 1 of 3 resident (R1) reviewed who required the use of a transfer belt during transfers reviewed for falls. R1 sustained harm when staff failed to implement the use of a transfer belt during a transfer to the bathroom. R1 fell , sustained a bilateral nasal bone fracture, laceration on the forehead, was sent to the emergency department (ED) requiring medical treatment. The facility implemented corrective action prior to the survey so the deficient practice was issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and no behaviors. […]

• No harm, potential for more than minimal, widespreadF880Jan 15, 2025

  Based on observation, interview and document review, the facility failed to implement appropriate donning/doffing of personal protective equipment (PPE) practices to prevent the spread of infection for 1 of 3 residents ( R21) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). This deficient practice had the potential to affect all 22 residents residing in the facility. […]

• No harm, potential for more than minimal, widespreadF812Dec 6, 2023

  Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators, were labeled, dated and discarded properly .This deficient practice had the potential to affect all 23 residents who were served food from the kitchen. Findings include: On 12/4/23 at 12:05 p.m., during an initial tour of the facility kitchen area with the dietary manager (DM), the following concerns were identified: Refrigerator: -large plastic container 3/4 full of thousand island with black crusty substance around the lid of the dressing opened 4/28/23. -large plastic container half full of Italian dressing opened and not dated. -large plastic container half full of thousand island dressing opened 5/26/23. […]

• No harm, potential for more than minimal, widespreadF851Dec 6, 2023

  Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 2), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 23 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified the following dates triggered for review: 4/23/23, 4/29/23, 4/30/23, 5/14/23, 5/20/23, 5/21/23, 5/27/23, 5/28/23, 6/3/23, 6/4/23, 6/10/23, and 6/17/23 for failure to have licensed nurse coverage 24 hours per day. […]