Grace Home Inc.

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF658Mar 7, 2025

  Based on observation, interview and record review, the facility failed to maintain professional standards of quality for 10 of 32 sampled residents (4, 5, 8, 11, 13, 14, 15, 23, 24, and 28) when: 1. Resident 15 had a specialty mattress (perimeter mattress or raised perimeter mattress refers to a mattress designed with a raised edge or bolster [a long pillow or cushion] along the sides to prevent falls) on her bed without a physician order or care plan in place. This failure of not having a physician order or implementing a comprehensive care plan for Resident 15 had the potential to place Resident 15's safety at risk and her specific needs not being met. 2. […]

• No harm, potential for more than minimal, widespreadF727Mar 7, 2025

  Based on observation and interview, the facility failed to have a Registered Nurse (RN) in the facility at least 8 consecutive hours in a day. This failure had the potential to put Residents' safety at risk and their specific needs not being met. Findings: During an interview on 3/5/25 at 11:55 p.m., with the Director of Staff Development (DSD), the DSD stated she was covering for the Director of Nursing because he left at 11 a.m. The DSD stated she was a Licensed Vocational Nurse and not an RN. During an observation on 3/5/25 at 4:30 p.m., while walking throughout the entire facility, there appeared to be no RN currently in the building. During an interview on 3/5/25 at 5:15 p.m., with the Administrator (ADM), the ADM stated there was not an RN currently in the building. […]

• No harm, potential for more than minimal, widespreadF761Mar 7, 2025

  Based on observation, interview, and record review, the facility failed to ensure safe and secure storage of medications when: 1. Medication room was propped open and unattended by authorized staff. This failure had the potential to place facility at risk for unauthorized access to medication room and possible drug diversion. 2. Resident 5's Hydrocortisone 2.5% topical cream was beyond the discard date. This failure had the potential for residents to receive expired medications that were no longer effective. Findings: 1. During an observation on 3/4/25 at 12:45 p.m. at the nursing station, the medication storage room at the nursing station was propped open and unattended. […]

• No harm, potential for more than minimal, widespreadF812Mar 7, 2025

  Based on observation, interview and record review the facility failed to label stored food and properly clean the kitchen for 31 of 33 Residents (Resident 1, 2, 3, 5, 6, 7, 8, 9, 10, 12, 13, 14,15,16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33) who eat food from the facility when: 1. Pastrami was not labeled with a thaw date after being moved from the freezer to the refrigerator. 2. The quaternary ammonium sanitizer solution used to clean the food preparation surfaces after breakfast tested at 150 ppm (parts per million), below the targeted 200-400 ppm. 3. Staff failed to document the dishwashing machine temperature log, prior to the start of washing, at each meal, to ensure proper sanitation of all dishware and trays. […]

• No harm, potential for more than minimal, widespreadF812Mar 1, 2024

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices were followed in the kitchen when there was no air gap (a space provided to prevent unsanitary water from flowing back into the sink) under the three-compartment food preparation sink. This failure placed 32 of 32 residents at risk for food contamination and foodborne illness. Findings: During a concurrent observation and interview on 2/28/24 at 11:37 a.m., with Dietary Aid (DA)1, in the kitchen, DA 1 stated food was prepared in the three-compartment sink. The food was prepared in the third compartment and the garbage disposal was also in the third compartment. […]